Monthly Archives: August 2008

Pride goeth before destruction, and an haughty spirit before a fall.
Better it is to be of an humble spirit with the lowly, than to divide the spoil with the proud.
– Proverbs 16: 18-19

One of the redeeming experiences on my Psychiatry rotation is the time I spend with the Veteran’s Affairs Substance Abuse clinic in Alcoholics/Narcotics Anonymous groups. Unlike most of my Psychiatry experiences, the AA/NA groups have been universally encouraging and insightful. Insight is a rare trait to find on the inpatient closed psychiatric ward, and it is refreshing to be with addicts who help one another gain clarity in evaluating their condition, relapse triggers, and positive development. Today, I had the privilege of sharing some of my thoughts with one group of veterans about Step 1. In recognizing one’s powerlessness to alcohol/drugs and understanding the uncontrollable consequences of substance abuse, I noted that there is a subtle but important distinction between pride and strength. For the sickest patients I have seen during my clerkship, pride is one of the greatest and most common flaws: to me, it is the delusion that one is in control when one is not in control. It is the delusion that you can skip taking your antipsychotic and mood stabilizing medications and still regulate mood and not resort to violence. It is the delusion that the world is somehow always against you, and that you have no role in causing your problems. It is the delusion that your suffering is unique and entitles you to special treatment. On the other hand, the ones that have the best chances of recovery (like the AA/NA veterans) are the patients who have the strength to be humble, to recognize their diseases, and to make the commitment to take ownership of their problems and be guided through the treatment process by another. Inner strength gives confidence, not pride, for strength is accompanied by clarity while pride and arrogance are blinded without insight.

Notably, AA and NA have a strong spiritual theme underlying the treatment process. Many people think that spirituality and religion have few meaningful roles in the practice of medicine, but now that I have been exposed to inpatient Psychiatry, I beg to differ. I am not a religious man, but I do express spirituality through a belief in a higher power that, for convenience when sharing, I call God. When people truly believe in a higher power, that belief supports a measure of humility that encourages them to take time to step back and reevaluate their situations. Many of the patients I have encountered on the inpatient psychiatric ward, with their grandiose and persecutory delusions, lack or abandon this sort of belief. I hesitate to think of them as “God-less,” but it is apparent when some individuals lose the grounding that allows most people to interact and participate in shared communities. They do not share, because everything, whether praise or persecution, must be about them in their minds, leaving no room for a God (unless the delusion involves hyperreligiosity, which may sometimes be a delusion of grandeur) or for anyone else. Since they believe everyone else has a problem but not them, they are unable to heal. On the other hand, those patients with some spirituality or at least the capacity for self-reflection and self-evaluation are better able to understand how their diseases are affecting their lives and what steps they must take to allow for a process of healing.

Though there may not always be the time or reason, I hope my patients will be comfortable expressing their spirituality with me (regardless of religion or lack thereof). If nothing else, I hope to take from this Psychiatry clerkship this message, the opening prayer from each AA/NA meeting:

“God, grant me serenity to accept the things I cannot change,
courage to change the things I can,
and wisdom to know the difference.”

So far, my Psychiatry clerkship has been a boon for several reasons:

(1) Psychiatry has given me the opportunity to explore the complexities of the mind and its potential dysfunctional behaviors. Accordingly, it has given me a chance to scrutinize my own thought processes, including, most recently, my rapid growing passion for Neurology. Additionally, it has given me an acute awareness of my impressions and attitudes toward my patients.

(2) Although I had equal intellectual interest in both Neurology and Psychiatry from my second year Neuropathology and Human Behavior coursework, my Psychiatry rotation has offered me clarity: I now know that it is possible for me to find a subject interesting without wanting to work in the field. By contrast, my feelings for Psychiatry have accentuated my interest in Neurology as a possible career pathway with the knowledge that I won’t fall in love with every field through which I rotate. Prior to my rotations, I had equal magnitudes of bias against both Neurology and Psychiatry, but my bias against Neurology dissolved with new knowledge, familiarity, and experience (unlike my bias against Psychiatry, which has largely been confirmed and solidified despite my increasing respect for those practicing in the field).

(3) Psychiatry has not only given me the intellectual opportunity to think about my thought processes and career planning… it has also offered me the time to do so! The days have been considerably shorter than those on Neurology, giving me time to do extra reading in Neurology and Medicine.

However, despite these benefits, this Psychiatry clerkship has been a twisted journey through the dark side of medicine. For a number of reasons, I cannot see myself pursuing a career in this field under any circumstance:

(1) By necessity, Psychiatry is far more paternalistic than any other field of medicine. In other fields, the physician and the patient can be partners with equal input into the relationship and effort. The physician can use reason and knowledge to convince a patient that a particular therapeutic regimen is the best option, and the patient can use her intellectual capabilities and logic to navigate the medical reasoning and adhere to the treatment plan. For the most part, gone are the days when doctors would simply say, “Do this, and you will get better” without further explanation; patient education is an essential part of medical treatment. However, in inpatient Psychiatry, this equal relationship does not and cannot exist. Mental illnesses are only problems when they impair an individual’s functioning in activities of daily life (work, family life, social interactions, following basic legal standards, etc.). In order for a patient to be admitted to an inpatient psychiatric ward, there is almost always a legal issue: threatening suicide or homicide, violent or aggressive behavior, disturbing the peace with psychotic behavior, etc. In treating a patient with poor judgment and insight, the likelihood of actively engaging a patient’s reasoning or logic is very low. Accordingly, the patient’s role in treatment planning is often minimal, at least initially, leaving the physician in the position of “always being right.” This creates great potential for antagonism in the patient-doctor relationship.

Would I find much personal reward in a field where one is frequently arguing with patients who express their hatred of you? No. From my observations, when confronting oppositional behavior, I suspect that many inpatient psychiatrists find purpose in keeping the world safe from the dangerous and volatile minds and behaviors of their more psychotic and delusional patients. But that would not be a powerful enough motivator for me.

(2) Countertransference refers to the emotions a physician feels for his or her patient (sometimes displaced from another person to the patient who is reminiscent of the former). By my nature and commitment, I have sought not to lay judgments upon my patients. Nonetheless, this has not restricted me from developing friendly interactions with all but three: two of the patients were comatose, and the third is a chronic paranoid schizophrenic (CPS) who is currently floridly delusional. I have had several CPS patients so far, all of whom were relatively easy to manage and talk to without argument or the development of negative countertransference. Furthermore, until my most recent patient, I have not triggered or encountered significant paranoid delusions extending to myself and the treatment team. I have generally served as the “patient advocate” to voice their concerns. Nonetheless, I now have the opportunity to work with an openly oppositional and confrontational patient who, despite my reassurances and explanations, now thinks I’m “racist” and “trying to single (him) out.” I would like to talk to him about another of my CPS patients of the same race, size, gender, and difficult legal background (homicide), and my friendly and professional interactions with him, but it is clear that logic and reasoning will not work for this patient.

The difficult part for me is that I have been willing and perhaps even eager to give this patient the benefit of the doubt (considering he was committed by a family member who provided the opposite, guilt-assigning story to his own). I was even surprised when my attending remarked this morning that this patient is very sick, as he otherwise appears reasonably high functioning. However, I now understand my attending’s astute assessment: his thoughts are truly, extensively delusional with little or no grounding in reality. In some ways, I feel very sad for him: his delusions of victimization may prove self-fulfilling, as his confrontational behavior might prolong his hospital stay or get him committed to a more high-security facility. On the other hand, my sympathy has faded with the rapid surfacing of his delusional and confrontational behavior, making the allegations of his wife-beating, treatment noncompliance, and poor outpatient functioning much more believable.

In this situation, it is requiring some effort on my part to constantly remove myself from the position of judge, and the result is that I have a painstakingly neutral attitude toward this patient. For me, this position is far from ideal: I would like to encourage and contribute to the betterment of the lives and health of my patients. In this case, it is more likely that I will be in the position of cooly watching this patient’s descent, indifferent to his fate, but rather, more concerned with the fate of those he might harm.

I feel the numbness I observed in our psychiatrists toward many of the patients. I look forward to the end of this rotation.

Lately, I have become inordinately excited about the prospect of pursuing the very new field of Endovascular Surgical Neuroradiology (aka Interventional Neurology) as a potential career pathway. A few weeks ago, my major three interests were Pulmonary-Critical Care, Interventional Cardiology, and most recently, Neurology. This new field seems to encompass several of my medical interests, all of which I might feel sad to abandon if I had to choose one over another. But now I wonder: how deep does this new interest of mine find its roots?

I believe that the various fields in medicine often attract people with similar interests and personalities (that extend beyond basic stereotypes). I have worked with doctors in a few fields so far that have impressed upon me particular styles and characteristics. For example, my fiancée loves mystery novels and puzzles (e.g. Sudoku, crossword puzzles, Bejeweled, etc.): I think this detective and puzzler archetype fits in nicely with Neurology in which the physician both methodically and insightfully unravels the mysteries of the injured or dysfunctional brain. In Cardiology, I find the doctors are much like cowboys: there’s an aggressiveness and pervasive confidence (especially given the many successes in the field), and in the Catheter Lab, it’s possible for a single doctor (with the help of a scrub nurse or other assistant) to save a person’s life (unlike in many surgeries, where the effort is much more team-based). Psychiatry has presented a variety of personality types and working styles to me, but the common theme I have found is the storyteller core: at the center of their interests, these doctors are interested in the elaborate life stories of their patients, and they often relate to others through telling their own life stories. Lastly, Infectious Disease physicians are the true biologists willing to confront the intrusion of nature into our lives: while other doctors might find fascination in disease marking the body’s failure to function properly, these ID doctors find a world of wonder in the numerous, rapidly-adapting microorganisms that wage war upon our bodies.

I have not been sure how my prior interests could connect with my future pursuits: in other words, I have not known how to draw strength and energy from the things that have interested me all throughout my life thus far. I don’t necessarily see myself at this time as the detective or the cowboy. What sort of things have I really liked and enjoyed that might reflect a core, underlying mode of operation?

Video games. I have always liked playing video games, despite my father’s constant insistence that I would fail out of school at the rate I played them. In particular, there is one long series of games that I have always enjoyed that I feel serves as an amusing, if not fairly accurate, allegory of why I am suddenly so passionate about this new field of medicine: The Legend of Zelda.

For those unfamiliar with the classic Nintendo-console series, each installment features the Hero’s Journey of a young, ordinary man with an extraordinary task and destiny (to save his homeland from evil and ruin). The series follows his journey as he fights his way through a variety of dungeons and fortresses, usually solving environmental puzzles and picking up new tools and allies along the way as he tries to reach his objective. To my surprise, the adventure parallels that interventional path to treatment of vascular diseases and highlights some of my core personal interests that can be applied to medicine!

Step 1: You have been summoned by the Great Deku Tree!

One of the biggest obstacles to the treatment of stroke is the time it takes for its victims to realize that they are suffering from one. Time is brain (much like “Time is muscle,” the slogan of cardiologists treating heart attacks), and there always exists the problem that something must be done before it’s too late! At this time, the main FDA-approved treatment is the intravenous use of tPA or tissue plasminogen activator in ischemic strokes (the vast majority of strokes), an enzyme that breaks up clots but must be used within three hours of the start of symptoms. After that point, tPA can actually increase the potential hemorrhagic conversion of an ischemic stroke, changing the nature of the disease from a vessel occlusive disease (i.e. nutrient/oxygen-started brain) to a bleeding disease (i.e. bleeding into the brain tissue and causing direct damage and mass effects). New interventional treatments (discussed below) can extend the treatment window to 6-8 hours or more. Nonetheless, time is of the essence!

It is important that family members and friends recognize common symptoms of stroke because patients are often in denial of the severity or implications of their symptoms. You can save the life of a loved one this way!

Step 2: Go, Epona, go! We have no time to lose!

It breaks my heart, but I understand why many (poor) people avoid calling the ambulance: the bills can be very expensive! ($1000+) However, if there’s one instance when it is absolutely necessary to get an ambulance ride as opposed to calling a friend or family member or driving oneself to the ED, it is with a suspected stroke (even more so than with heart attacks, in my opinion, since a heart can be augmented or replaced unlike the brain). Furthermore, calling an ambulance gives the medical team advanced notice that you or a loved one might be having a stroke, thus speeding up the arrival of treatment and avoiding the necessity for triage upon arrival in the ED. Stroke Team Activation! (At this time, if I were an Interventional Neurologist and was at home, I would get paged and would be rushing to the hospital. If I were at the hospital, I would be getting the CT scan, tPA in the ICU, and Catheter Lab ready for possible treatment.) Every minute counts.

Step 3: You have received the Map!

One of the first things that needs to be determined upon arrival is the nature of the stroke: is it an occlusive (ischemic) stroke or a bleeding (hemorrhagic) stroke? 80-85% of strokes are ischemic, and those are the ones that can be treated with tPA and interventional techniques. Hemorrhagic strokes are treated differently, but if you give these patients tPA, the damage gets even worse since you are giving a medication that breaks up clots (that would otherwise stop the bleeding)! So, noncontrast head CT, stat!

If the patient arrived within three hours of the onset of an ischemic stroke, we can treat with tPA in the Intensive Care Unit (stroke patients require specialized care in the first 24-72 hours that differs from most patients, such as keeping the bed flat, aggressive temperature control < 99°F, tight control of blood glucose, maintaining “permissive hypertension,” etc.), open up the blockage, and minimize any damage. However, what happens if the patient arrives after the three hour deadline? Then we have to assess whether an interventional procedure is possible and indicated. Where is the occlusion? Let’s take a look!

Angiography allows interventional neurologists to determine where a blood vessel is occluded by a clot, thus setting the goal for an interventional procedure. The angiogram provides a “map” to the occluded vessel, and the interventionalist can maneuver a microcatheter through the blood vessels to either deliver tPA directly into the clot (to minimize hemorrhagic conversion or damage elsewhere) or use a mechanical device to break up or pull out the clot. Is the patient aware of the procedural risks and the consequences with and without interventional treatment? Does the patient consent? Yes? Let’s go!

Step 4: Over, sideways, and under

My favorite games usually involve environmental puzzles: given the tools you have, you need to figure out a way to get from point A to point B, often requiring some maneuvering and finesse. To me, this embodies the practice of interventional techniques: you have to thread a thin wire through the blood vessels of the body, around twists and turns, beyond bifurcations (forks in the road), and into the areas of occlusion or damage. This is not always a straightforward process, and this is where skilled hands are an asset! I have been complimented various times throughout my life (including by physicians) about my hand skill and motor coordination, but I have little interest in Surgery as a potential career path and lifestyle. Nonetheless, I would like to use my hands to help heal and treat those suffering from disease, and interventional procedures may offer me this chance.

Step 5: The Final Boss

Upon arriving at the site of injury, the moment of truth presents itself: will I succeed in breaking and removing the clot without complication and collateral damage? How can I best accomplish this goal in this situation?

So far, the options of intra-arterial thrombolysis (with tPA), mechanical clot thrombolysis, and clot retrieval. All of them constitute precision strikes on the culprit clot.

Step 6: Success!

The clot has been removed, and the vessel has been revascularized! The patient can be sent back to the ICU for post-treatment care. During my time with the Stroke service, I had the chance to witness the marked difference in outcome between a patients who received tPA in time and those who were not able to be treated due to their arrival after the three hour deadline. Many people survive strokes without treatment, but it is not just a matter of life and death: it is also a matter of disability and quality of life after the stroke, as many people are permanently disabled (physically and/or mentally) by strokes, the leading cause of long-term disability worldwide. Interventional techniques offer hope of extending the treatment window and reducing the overall mortality and morbidity from the disease.

Nonetheless, the medical care does not end there. Patient education and secondary prevention of stroke is essential to prevent the ordeal from occurring again. Or ideally, we can prevent the strokes from ever happening in the first place with primary prevention and care!


This has been a light-hearted approach to exploring how my past interests reflect core objectives that I can achieve in my future career and engrained principles and character traits that I would like to draw upon to make each day a worthwhile adventure. Perhaps for the first time, I am thinking less about the professional experience in each field based on current standards and practices and more about what things can be in the future.

And to the future of medicine and those I hope to save, I will bring:

The resolve to protect without hesitation,
the strength to endure in the face of everlasting darkness

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