Psychiatry at the Mental Health Services of San Joaquin County, Stockton

Today was the last day of my psychiatry rotation at the Mental Health Services of San Joaquin County, and I am genuinely going to miss this rotation. The staff and psychiatrists on site were so kind to me, the patients were extremely interesting, and the days were very short-getting home by about 3pm on average! Really the only downside to this rotation was the commute- from Benicia to Stockton its a good 1 hour and 30 min. Interestingly, driving 3 hours per day really started to wear on my bones and joints. I have a whole new appreciation for what truck drivers have to endure on a daily basis.

My preceptor was Dr. Silver, who has spent years treating patients at this psychiatric health facility (PHF). Dr. Silver was actually there even before all of the state hospitals closed in 1982. Rotating at the PHF, I was able to see how integral this kind of facility is for ensuring the health and safety of many individuals. What is upsetting is that in order for the county to be adequately paid for providing these services, they need to convert one of their units to a 23 hour facility. I can't think of many patients I saw in the PHF whom would have been ok to go home in less than 24 hours. It often takes a few days to get the meds right and to even get the entire story regarding the patients psychiatric health history. Even patients who are not psychotic but simply depressed should technically be in the facility for long enough to make sure the anti-depressants they are placed on are working. The general trend right now is that psychiatry is becoming a mainly out-patient-based field, mostly due to insurance reimbursement issues and lack of state/federal funding. We're experiencing what is called a "revolving-door phenomenon," where patients are sent on their way with meds, can't continue to take them for a variety of reasons sometimes specific to their disorder and sometimes just specific to having a disability, so they decompensate and wind up back in the facility, if they are lucky enough to be brought to a PHF. Some of the patients decompensate so badly that they wind up in prison. 20% of the 2 million Americans who are currently incarcerated have mental health issues. Think closing the state hospitals was a good idea now? I could go on and on about this, but I am stepping off my soap box...

At the PHF, patients come in with an extensive history of psychiatric problems, and Dr. Silver is always so open to re-examining the differential diagnosis. The list is always extremely long and its very hard to tell what specific disorder a patient has- many times because there are several things going on at once. We saw the term "Psychotic disorder NOS" (not otherwise specified) and "personality disorder NOS" were some of the more common diagnoses entered into Axis I and II respectively by crisis workers. About 70% of the patients at PHF fall into the psychotic category- people with schizophrenia, schizoaffective disorder, bipolar, bipolar with psychotic symptoms. 10% were depressed/suicidality/danger to others, and the other 10% were composed of patients with various diagnoses- some of them were just very hard to pinpoint. We had one patient who had been diagnosed with postpartum psychosis and two patients who claimed they had dissociative identity disorder (formerly known as multiple personality disorder) although I honestly think neither of them had it.

Another truly interesting experience was listening to the patients. I loved hearing them talk, looking for thought disorders, faulty logic, appropriate responsiveness to cues, etc. We had quite a few patients with flight of ideas, word salad, some who made up words, some who spoke in rhymes, and some that repeated what we said only.

I felt more safe on this rotation than I have on many other rotations, simply because there were always support staff around us during rounds and keeping watch in the wards. Brad and I went to the San Joaquin County Jail today to tour the facility and we felt very safe there as well. I felt much less safe on ortho surg with Dr. Welborn when we went to the 7th floor of DMC to see the prisoners- we would have them take off the cuffs in order to examine them at times- scary when you think about how unpredictable they can be. Bottom line is never to find yourself in a room alone with a patient when you have ANY reservations about the situation. One other thought related to the prisons- just remind me to commit a crime the next time I break a bone so that I can go to jail and get the fabulous, free health care that prisoners get- paid for by all of you lovely tax payers. We criminals appreciate all you do for us ;)

Next week I start my family medicine rotation at Brookside, which is right across from DMC in San Pablo. I am stoked to finally participate in my FM and internal medicine rotations. Kind of backwards if you ask me- I would have benefited greatly from having all of the nitty gritty medicine stuff first. Guess its also nice to have it right before I take step 2. If you are reading this as a 1st or 2nd year from Touro and you are trying to decide whether to have a psychation or a real psych rotation, I will just say this- you can't escape psych! Especially if you are considering primary care, I would not skimp on your psych rotation one bit. Thanks for reading!

Student D.O. of the Year!

Tonight I received an E-mail from the TUCOM President that made my jaw drop and hit the floor. I am the 2011 TUCOM Student D.O. of the Year! It is still sinking in... wow!

I just want to thank friends and family for your warm messages! I am so humbled by this honor, and as I have said to a few of you already, I feel like Student D.O. of the Year is really more of a reflection of the Touro - CA Community. I have been able to acquire knowledge and wisdom from the best- and you all have helped me learn more than I ever thought I would in just 2.5 years of med school thus far! What an incredible journey it has been and I am so excited for what lies ahead!

The SDOY application consisted a CV/ list of achievements, and an essay response. My response to last year's question can be found in the blog under Feb 2010, I think. For those who are curious, I have pasted my response to this year's prompt below (word limit was much shorter than last year):

"Recent analysis from the Centers for Disease Control and Prevention reveals that if current trends continue, as many as 1 in 3 adults in the United States could have Type II Diabetes by the year 20501. What measures will you take to help prevent this outcome among your patients?

Source:
1. Centers for Disease Control and Prevention. (2010, October 22). Number of Americans with diabetes expected to double or triple by 2050 [press release]. Retrieved from http://www.cdc.gov/media/pressrel/2010/r101022.html."

In 2010, it was estimated that 285 million people had diabetes, and predictions by the International Diabetes Association indicate that this number will increase to 438 million by 2030. Decreasing the incidence and prevalence of diabetes will take a major effort to remove the barriers to prevention, which are largely cultural, social, economic, psychological, and educational. As a future physician, I should play a major role in this effort by developing competency in diabetes prevention and management, and influencing the removal of barriers to behavioral change.

According to the National Institute of Health, those at high risk of developing diabetes who can implement dietary changes, develop healthy coping skills, participate in support groups, set goals like losing 5-7% of their body weight, and get at least 150 minutes of moderate physical activity per week will decrease diabetes risk by 58%. In my practice, I will encourage patients to take responsibility for their health and motivate them to implement these habits and goals. Studies by Prochaska & DiClemente (1986) have shown that a technique called motivational interviewing can help physicians identify the level of intervention appropriate for patients’ levels willingness to make changes in their lives. According to this research, by focusing on my patients’ level of readiness to make lifestyle changes, I can create individualized diabetes prevention and management recommendations for my patients. Believing in my patients’ ability to become healthy, I can open the door for them to carry out a self-motivated program of lifestyle changes that can reduce their risk for diabetes and even reduce diabetes-related complications in those who already have the disease. Once patients start to implement their diabetes prevention lifestyle changes, I will encourage them to become health mentors for their families. A community effort would help make leading a healthy lifestyle part of the norm, which would alleviate some of the societal psychological barriers to healthy living.

My colleagues and I can also help decrease the incidence of diabetes by leading the effort in designing and implementing community programs directed at increasing physical activity, healthy eating, and health literacy. According to studies by Thompson (1995) and Pate (2003), more than fifty percent of all US adults do not get the recommended amount of exercise needed per week to reduce diabetes risk, and two-thirds of all adults in the US have BMI’s of over twenty-five, which means that most people are overweight. This statistic points to the need for programs aimed at reducing diabetes in the overweight and obese population, focusing on diet and exercise. The National Diabetes Prevention Program, which launched in April 2010, is helping communities plan and execute workshops and educational events directed at diabetes prevention through life-style changes in this population. Another program, called Passport to health, works with families on managing their weight and preventing obesity-related health problems. Physicians should advocate to have these programs and other national health awareness tools shared with their communities.

One of the best ways to get the community together in a collective effort towards health and prevention is to promote the development and use of community centers. These facilities provide space for workshops, support groups, mobile health clinics, communal kitchens, and local gardening space. My colleagues and I should advocate for the creation of supportive facilities that successfully promote preventive health practices within our patient population. We should recruit students and professionals from the health care field to volunteer at these facilities by running workshops and free health clinics. The goal in this effort should be to teach clients about health maintenance and connect them with local resources.

If we focus on the effort to overcome barriers to diabetes prevention within our communities and ourselves, we can successfully reduce the prevalence of diabetes in the US population. I believe I can help decrease the incidence of diabetes by helping patients realize their unique role in the greater health of the community, and I can reinforce their health through education and preventative action. Most importantly, I must live a healthy life style and lead by example, encouraging patients to personify the words of Mahatma Gandhi, to “Be the change you wish to see in the world.”