Talk given at Career Day, Trafalgar School for Girls, Montreal , on 1998-11-26; 1999-11-30; and 2001-1-23.
I would like to tell you a story about a patient who I’ll call Mr. A. I first met Mr. A. in July. He had been referred to Consultation-Liaison Psychiatry at the Jewish General Hospital, where I work, by the doctors on the medical floor where Mr. A. was hospitalized. I went to see him together with Dr. B., a psychiatry resident that I was supervising.
Mr. A. was a 43 year old single man, living alone but with sitters 16 hours each day, seven days a week. He paid for the sitters mostly himself, as he got a disability pension from a government arts agency where he used to work, because of his severe osteoporosis. One of these sitters had described Mr. A. as having a “Howard Hughes syndrome”; that is, Mr. A. had not gone out of his house for the previous 3 years, and during that time had refused to bathe, or even to have the windows opened.
Mr. A. had presented to the Emergency Room with a painful and swollen knee. As he refused to have diagnostic tests done, and was also refusing to eat or drink, he was referred to psychiatry. The psychiatrist found him to be competent to refuse, and accordingly Mr. A. was sent home.
Two days later, Mr. A. returned to the ER, this time with a fever. He talked about killing himself, and was again sent to see psychiatry. This time, he was admitted to 4 East, the inpatient psychiatric unit, where he stayed for 2 days before being transferred to a medical floor for treatment of a pneumonia. After 3 weeks, he was discharged to a private nursing home.
He only lasted 9 days there. The nursing home sent him back to the Emergency Room as he was complaining of severe pain, and wasn’t eating because he insisted he couldn’t swallow. He was again admitted to the medical floor to treat dehydration and pneumonia.
I would like to summarize his medical problems at this point:
First, Mr. A. had severe wasting. Although 6 feet tall, he only weighed 87 pounds. This Body Mass Index of 13 was felt to be “incompatible with life”.
Second, he had severe osteoporosis, without any satisfactory explanation.
Third, he had had very high prolactin levels since 1993. Prolactin is a hormone which among other things, stimulates the secretion of milk in breast-feeding mothers. In males, the range of normal is from 5 to 15. Mr. A. had levels over 1500. Again, no good explanation.
On the medical ward, Mr. A. was a difficult patient, frequently refusing treatments and medications. He had his own sitters in to look after him, would order food to be delivered, and refused to go for X-ray tests or CAT scans.
The ward staff also found him peculiar: he looked bizarre with his extremely skinny frame, long hair, and long, matted, and drool-flecked beard. Constantly drooling and spitting up saliva, he would go through 6 boxes of Kleenex per day. He ate with his fingers, and talked in a peculiar, high-pitched voice. His speech was interspersed with a variety of strange sounds: grunts, squeaks, and muffled barks. He also had tics involving his head and eyebrows.
It seemed to Dr. Brebion and I that the internal medicine doctors had given up on him. They felt he had a personality disorder, as well as an eating disorder, and talked about sending him to the Eating Disorders Unit at Douglas Hospital, or just finding a nursing home for him.
In reviewing his chart, Dr. Brebion and I found that Mr. A. had already been seen by 4 different psychiatrists during the previous two months, who had documented many signs and symptoms of both Obsessive-Compulsive Disorder and of Tourette’s Syndrome.
The patient was quite aware that he had both: Tourette’s had been diagnosed in January 1996 by a neurologist. Mr. A. had himself figured out that he must have OCD when he developed a handwashing compulsion at the beginning of 1995. He read widely about his various symptoms, and took an extreme interest in trying to understand his medical conditions.
Dr. Brebion and I were also quite interested in Mr. A. We found that if you took time to sit down and listen carefully to him, you would discover that behind all the disgusting mannerisms and drooling there was an intelligent, articulate person who was genuinely in pain, frightened, and suffering.
He couldn’t understand why he wasn’t being adequately worked up for his medical problems. His refusal to go for imaging tests was based on fear: fear of the excruciating pain he knew he would suffer from lying on a hard CT scanner table. A well-founded fear, as his near-total absence of body fat meant that his bones, muscles, and skin had no protective padding.
He was also very worried that the movements required to get on and off the table would result in broken bones. Again, a valid concern; he’d had a number of spontaneous fractures, including broken ribs just from coughing, due to his severe osteoporosis.
Our interest was also piqued because Mr. A’s doctors had made up their minds that “it’s all in his head”. It was clear to us that he suffered from at least one clearly neurological condition, the Tourette’s, and the documented severity of his various medical conditions made it unlikely that they were psychological in origin.
A prolactin level of over 200 is almost certain to be a tumour of the pituitary gland. Even though an MRI the previous year at the Montreal General Hospital had been read as negative, we thought it was important to look into this.
We felt that our role was to advocate for the patient, to have these issues adequately investigated.
We were also fascinated by the co-occurrence of OCD and Tourette’s in this man, and the possibility that we had come across an adult form of a syndrome, in which these diseases come about as a result of having a strep infection, such as strep throat or scarlet fever.
In our role as advocates, we convinced Mr. A. to have a CT scan, to which he agreed if the table were well-padded. We also talked medicine into ordering a CT scan right away, before the patient changed his mind. He had the scan done the same day, and it showed a grapefruit-sized tumour in the pituitary gland.
Briefly, Mr. A. had neurosurgery. Unfortunately, the tumour could not be entirely removed. Mr. A. agreed to take medication for the OCD and Tourette’s, with some symptomatic improvement. He also accepted injections of testosterone, and was able to gain a little weight before his discharge near the end of October. Dr. Brebion arranged followup for him at the OCD/Tourette’s clinic at the Royal Victoria Hospital.
Why did I tell this story? I think it exemplifies what I find most exciting about psychiatry: it’s a lot like detective work, or solving puzzles. You search out clues, look for pieces that fit together, you get to use the creative parts of your mind; lateral thinking often pays off.
Of course, that’s true of many other fields; I can think of engineering, or research, or even playing the stock market, as providing the same kind of intellectual challenge. So why psychiatry?
Basically, psychiatrists help people, people who are suffering, in psychological pain, men and women who may be so desperate that they are ready to take their own lives. Did you know that depression affects ten percent of the population at one time or another? Look around you: 4 or 5 people in this room will become depressed. Other serious mental disorders like schizophrenia or manic-depressive illness each affect about one percent of the population. Clearly, psychiatry is a growth industry.
Although the popular image of “shrinks” is of short, balding men with german accents who take notes and stroke their little goatee beards while their patients lie on a couch relating their dreams, the reality is that psychiatrists are medical doctors who are responsible for diagnosing and treating serious mental disorders. We use a whole range of treatments, including psychotherapy, medications, even electroconvulsive therapy, which you know as shock treatment.
Not only that, the treatments we use are remarkably effective, considering how chronic the illnesses we treat are. Antidepressant medications are effective in 60 to 70% of patients; electroconvulsive therapy works in 80 to 90% of cases of depression. And this is not just treating symptoms: these therapies actually take away the depression. Compare this to the best treatments for other chronic illnesses, such as diabetes, or arthritis, or Parkinson’s disease, or multiple sclerosis, or kidney disease. The best you can expect is reasonable control of some of the symptoms for some of the time.
And our patients are grateful for what we do. I’ve had people say, “you know, doctor, this medication is like a miracle. I’ve never felt this good in my entire life!”
And because psychiatrists are medical doctors, we enjoy many of the advantages that attract people to medicine.
We’re our own bosses, and without the risks that most people who are self-employed or become entrepreneurs face.
People respect and trust doctors. You don’t often hear the kind of nasty jokes that are told about lawyers; for example: “It was so cold in Toronto yesterday that the lawyers had their hands in their own pockets!” There are lots of jokes about psychiatrists, however. “How many psychiatrists does it take to change a light bulb? It only takes one, but the light bulb has to really want to change!”
What’s the difference between a surgeon, an internist, a psychiatrist, and a pathologist? A surgeon knows nothing but can do everything; an internist knows everything but can do nothing; a psychiatrist knows nothing and can do nothing; and a pathologist knows everything and can do everything, but it’s too late.
And in general, doctors make a good income. The bad news is, that many doctors are such poor financial managers that many cannot afford to retire, so they just keep on working. The good news is that psychiatrists in particular can often work well past normal retirement age.
Doctors are also quite mobile. Graduating from a Canadian or U.S. medical school, which takes four years, and completing a specialty training program, which takes 5 years for psychiatry, is usually sufficient to get a license to practise medicine just about anywhere.
There are downsides, however. Psychiatrists are the lowest-paid of any medical specialty, and Quebec medical specialists are the lowest paid in the country. So we’re really at the bottom of the heap. And working for the government means that many aspects of what we do are decided by bureaucrats in Quebec city. I can’t say that I’m impressed by their intelligence. To add insult to injury, doctors don’t get any of the cushy perks or pensions that other government employees get.
In spite of the drawbacks, I must say that I enjoy my work. It’s highly varied, each day is different, I work with nice people. The concept of working in multi-disciplinary teams has evolved more in psychiatry than in other areas of medicine, and it’s truly a pleasure to work in partnership with other professionals, including nurses, social workers, and occupational therapists.
I would like to tell you how I got into psychiatry in the first place. I initially graduated in electrical engineering from the university of Waterloo, and then worked in the field of computer systems engineering for 7 years before going back to school to study medicine. Before I could get into McGill, I had to take university-level biology at night school. It turned out that I was the second-oldest student in our class of 160. First, it meant that the inevitable blows to my self-esteem had less of an effect on me than they did on many of my classmates. When you work in a hospital as a medical student, and you round on all the patients on your floor in the morning with all the interns, residents, and attending staff doctors, it’s really a very rigid pecking order. The staff doctor asks impossible questions of the residents, who feel humiliated when they don’t know the answer, and take out their frustration on the interns, who in turn abuse the medical students. Some of my classmates were so unhappy, they would say, “I really don’t like this; I don’t know what I’m doing in medicine!” When I suggested, “why not switch to another career?”, they said, “Oh no, I can’t, it’s too late, I’ve got too much invested in this!”
Here’s what seems to happen: Suppose a two or three-year-old boy announces one day, “I’m gonna be a truck driver when I grow up!” everyone says, “that’s nice, Johnny”. If one day, he happens to say, “I’m gonna be a doctor!”, everyone cheers and says, super idea, Johnny, great kid, that John! And they never let him forget it! If Johnny ever were to announce that he’s decided he’s going to become an actor or a musician or anything else, all the relatives will ask in very disappointed tones, “what ever happened to becoming a doctor?” They will never let him forget; the rest of his life is programmed on this career path. Is there anybody here who knows already that they want to be a doctor?
In any case, when I did my psychiatry rotation as a medical student, it was such a pleasant change from the other rotations. People treated me as a human being! And we actually got to do psychotherapy with a patient that we saw twice a week for 6 weeks or so. This was mind-blowing, because we had the opportunity to actually make someone’s life better! In the rest of medicine, you’re lucky if you succeed in even getting the patient back to the same level of functioning and quality of life that they had before they became ill. But in psychiatry, people with personality disorders can learn to improve their lives significantly. My positive experience caused me to change direction: I had planned to become a family doctor, but how could I pass up something that I found so enjoyable?
A typical week
- Meeting re inpatients
- See patients
- Admit new patients
- Discharge patients
- Write orders
- Discuss with nursing staff
- Psychogeriatrics meeting
- Psychogeriatrics clinic
- Go to CLSC for case review meeting
- After lunch, a meeting re research
- Late afternoon, Elder Abuse Consultation Committee
- Journal club
- 4 east team meeting
- see inpatients
- psychogeriatrics clinic
- psycho-oncology clinic
- possibly attend Pain Clinic rounds
- Consultation-liaison team meeting
- See inpatients: family meeting
- Supervise resident
- Clinical Grand Rounds
- C-L patients
- 2nd call in ER
- Cover ER
- See inpatients
- C-L patients
- Palliative Care Rounds
- Psycho-oncology clinic
- Talks to community groups
What do other psychiatrists do?
- Private practice
How to start
- Health sciences in CEGEP
- Pre-Med or an undergraduate degree, eg Mcgill requires organic chemistry, biology
- 4 years med school
- 5 years residency training
Future of psychiatry
dichotomy between biological orientation and psychological
- Protocol for Management of Depressive Disorders in Cancer Patients
- A diet for life