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!
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