When attending seems like bad interviewer?

[closertofine]

Fortunately this isn't "my" attending, but another one I was shadowing in the ER. I think I kind of (maybe really) pissed him off. He said he had to interview the patient himself so he could do his dictation, so I was just there to observe the interview.

But (without giving away any identifying details, obviously), the patient presented as suicidal and looked to me for all the world like he honestly had the thoughts and feelings of a person who could end his life. Just desperate, hopeless, thinking he had absolutely no purpose left in life...my heart seriously went out to him.

And I know it's "wrong" to criticize or even question an attending's behavior...but throughout the interview, the attending sat almost with his back to the patient and barely even looked up as he asked questions and filled out the paperwork for admission.

The patient did get kind of hostile and cursed at the attending, asking why he had to answer all these questions that seem irrelevant when he is just desperate for some kind of immediate help. That's when I started talking, telling the patient calmly he just needed to hold on for these few minutes/hours until we can get these forms taken care of so we can start getting him the help he needs. And he did seem to be calmer after that.

But that was only the start of my involvement...I listened to the patient go on about his issues, mention his daughter and how he thinks she'd be better off without him...I was just sympathetic in general and told him how a daughter always needs her dad.

Then it was back to the attending's questions...which I do know are absolutely necessary for admission. But he just goes down the form of questions and asks each one exactly as it was written...and this is not a population necessarily used to that kind of vocabulary. So I broke in to "translate"...the attending asked something like "do you have any history of assaultive behaviors, legal difficulties, etc etc?" which I made into the more clear "have you ever hit anyone or been arrested before?"

After the interview, I was kind of debating with the attending over his view that the patient was just a malingerer with a personality disorder...I kept arguing that it just seemed so genuine to me (stupid naive me!). But turns out, there was an old chart on him (though he said he'd never been here before) with a similar problem.


OK, I'm too sleepy to think really straight...but I just felt like even though the "med student" title confers no special status anyway, and I admit there is a huge amount of stuff I still have to learn. But I still felt like in good conscience, I couldn't sit across from someone who was having these problems and just nod and smile or take notes.

I also know the initial assessment is not supposed to be therapy...but I still feel like (in all my previous pessimissm and cynicism), I didn't go into medicine to look away when people are hurting or even if they're pretending to be hurting! I guess that's just wanting to give everyone the benefit of the doubt, which I guess doesn't always work out that well.

Oh well, ramble over...post-call sleepiness kicking in...

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[Bobblehead]

You should be asking the person that's supposed to be teaching you something questions. Nothing wrong with asking or questioning people. No one's infallible.

I believe you've seen what these people will do to you after you've seen several or a dozen or hundreds of them, have been manipulated by them, seen how they game the system, seen how they tie up valuable resources, etc. The attending you were following likely has seen enough of these people

Also as you pointed out, this person has an old chart. Revolving door psychiatric disease isn't uncommon in the ER. These people as a whole have poor coping and survival skills. It's helpful to take cues from the ER nurses about how sick they think the person is. A lot of the time they'll be right on. Just watch out for those unexpected disasters.

Don't worry, you'll have that sensitivity beaten out of you soon enough, for better or for worse.

 

[closertofine]

You should be asking the person that's supposed to be teaching you something questions. Nothing wrong with asking or questioning people. No one's infallible.

I believe you've seen what these people will do to you after you've seen several or a dozen or hundreds of them, have been manipulated by them, seen how they game the system, seen how they tie up valuable resources, etc. The attending you were following likely has seen enough of these people

Also as you pointed out, this person has an old chart. Revolving door psychiatric disease isn't uncommon in the ER. These people as a whole have poor coping and survival skills. It's helpful to take cues from the ER nurses about how sick they think the person is. A lot of the time they'll be right on. Just watch out for those unexpected disasters.

Don't worry, you'll have that sensitivity beaten out of you soon enough, for better or for worse.

Yeah...I think that has already happened to some extent...I tend not to believe the "reasons" my drug-addicted patients give me for anything, etc. And I've realized it actually bothers me that I've become so suspicious of people's motives in such a short time.

So I guess I let this particular patient totally pull at my heartstrings by appearing so distraught and desperate. And probably my past experiences of feeling bad myself make me tend to believe someone acting like that.

We didn't find out that he had an old chart until after he'd been admitted, unfortunately! But coming straight out of the interview, the attending told me, "that's a classic sociopath," and I was shocked at how different his impression was from mine! But apparently he was right, I guess...so I did say I needed to work on my "gullibility skills" and I guess from now on, I should work on keeping my mouth shut a little more so I can learn more.

I agree about the nurses usually being right on, though...they didn't get a chance to see the patient much this time, but otherwise I've had that experience too. Oh well...I'll be back later today, so I think I'll stop by to see how this particular guy is faring and if he's now laughing and watching TV as my attending predicted.

 

[closertofine]

Oh, this may not be so relevant, and it probably just shows my naivete...but it does bother me when a patient is given a label like a personality disorder, and then from that time on, it seems like nothing the patient can say or do can redeem him or her to the treatment team.

I realize the personality disorder label means they have a pattern of acting and probably aren't going to do anything unusually redeeming...but it just seems to me like the epitome of judging people and putting them in one box, and then there is nothing they can do to get out of it. (And the team laughs at what the patient says behind his back because it is so "classic" for that disorder. I've even started becoming guilty of this myself in some of the more extreme cases).

OK, rant over!

 

[closertofine]

In the continued spirit of talking to myself (hey, I'm on psych!)...I was on tonight with a different attending who was wonderful with the patients and made me realize what an interview can and should be like. Maybe involving actually talking to and looking at patients instead of at a piece of paper, for a start!

And he got a lot more info out of patients with his approach too...even the paranoid guy high on crack admitted to drug use. Not that any interviewing style will reverse someone's personality problems or general manipulation of the system...but it was nice to see that there can still be some compassion or understanding regardless.

This guy was young, though, so I hope it's not inevitable for jadedness to set in with age. But even regardless of the attitude behind it, it seems like this approach gets much better results than the other attending's annoyed statements that 'there's this form I have to fill out with all this information, so you have to answer all the questions on it.'