Well, I Guess I Can Only Go Up From Here - Outpatient Psych

   When we started our rotations in the hospital this year, we were all very anxious and scared.  I think one of the things I feared the most was potentially crying in front of my superiors.  I am a very sensitive, emotional person, so sometimes I just can't help the waterworks.  And once you get the tears flowing, they do not stop!  Well, my worst fear already came true, so at least I got that out of the way!

   One of the residents and I were seeing a new patient who had recently been hospitalized for psychotic symptoms.  She immediately "split" my resident and I, deciding she absolutely hated me (for no reason whatsoever), and while she didn't really seem to like my resident either, she at least tolerated the resident.  A lot of times with patients who exhibit personality disorders, the traits are subtle, and it takes a few appointments for the behaviors to come through.  This patient, however, was SCREAMING Cluster B traits.  She was extremely hostile, entitled, and shamelessly condescended me for the 15 minutes I attempted to interview her.  I hung in there for a while, holding my ground and remaining calm, but she absolutely refused to talk to me because I was "too young, so don't know anything about life, and don't have the qualifications to help her."  My resident realized that my attempts weren't going anywhere, so she jumped in and took over.  Even after that, throughout the appointment the patient continued to be blatantly rude: smacking on and spilling her sandwich everywhere, taking out her makeup and staring at herself in her little mirror mid-sentence, and answering her phone three times during the appointment to have full-on conversations.  She had absolutely no disregard for my resident or I as human beings, and even while watching the rest of the interview, I was extremely uncomfortable as she repeatedly shot dirty looks in my direction.  The entire time, I just kept thinking to myself, "Is this really happening?!"

   In psych, there is something we call "countertransference,"  which is basically the emotions that we feel as physicians towards our patients.  Well, my countertransference with this patient was anger and inferiority.  After the patient left, I took a deep breath, and I said, "Wow. That was extremely hard for me."  My resident asked, "What part was the hardest?"  And then I just burst into tears.  I cried, "She was just so mean to me!  She made me feel like nobody!"  At that point, I feel like I became "patient" and my resident became "shrink" for a quick second.  She said some things to make me feel better, reassuring me that I had done a really good job with such a difficult patient.  It made me feel a little better when she told me I would do well in psychiatry because I really "feel" for my patients and am super perceptive of things most people don't pick up on.  And when we returned to discussing the patient, she reminded me that if this patient's interactions were that bad in an hour-long interview, how bad must they be in the rest of her life?  How unstable and turmoiled must her relationships be if this is the way she treats people?  So at that point, my anger with the patient turned into sympathy.  Her personality disorder(s) is the cause of all of her stressors, but she doesn't even realize it!  But hopefully with therapy, she can gain insight and make changes for the better.

   I've had some highs and lows on outpatient psych.  Obviously, bursting into tears in front of the senior resident was a low, but I learned a lot from that patient encounter.  Also, this might be counterintuitive, but I actually feel more confident after that disaster-of-an-interview, because most patient encounters from here on out will not be anything near as bad as that one.  If I could handle that uncomfortableness and remain calm, I think I can do it in any other situation too.  Another low point was getting goosebumps as a patient described to me how he thought about peeling people's skin off, or how he would like to rip his ex-girlfriend's body in half.  There have been some high points too, though.  It only takes one patient to tell me, "You're gonna be a great doctor someday!" to get me back out of a funk.  When I told this sweet old lady that she would be seeing someone else at her next appointment, she told me, "You're so sweet.  I'm gonna miss you and I don't even know you!"  These moments make it all worthwhile.

   In some ways, outpatient psych is actually harder than inpatient.  Longer hours, more patients.  Patients are more "normal", so it's easier to relate/connect with them, which starts to take an emotional toll on you.  On inpatient psych, it's easy to feel disconnected from the patients, to watch them from a distance, so I often found myself curious, amused, and at times simply entertained.  On outpatient psych, I find myself feeling much less entertained - now the patient's stories are just plain sad.