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The Laziest Hitman

Ben_3Ben Bryner -- There are a few important skills you learn during the third year of medical school. These are skills that you’ll need no matter what field you go into or what type of patients you see. Basically, you have to learn these during the third year because you can’t progress much further in medicine without learning them. The three main skills I’m thinking of are taking a history, doing a physical exam, and presenting a patient (summarizing their case in oral form for the rest of the team). Sure, you learn all kinds of other tricks, too, from inserting lines to suturing to delivering a baby, but these are specialized to certain disciplines and you won’t get much practice at any single one.

The theory is that those three skills are the essential tools you need to be able to diagnose patients with any given complaint. And while you learn some principles of treatment in medical school, learning actual treatment modalities is the formal goal of residency training, so they are less emphasized in medical school and on students’ licensing exams. Instead, those three fundamental skills are emphasized on each clinical rotation, and this is the main rationale, I think, for making students rotate through all the major areas of the hospital.

All this is to explain that the psychiatry rotation is actually useful for those of us who plan to spend more time poking scalpels, endoscopes, or cardiac catheters into patients rather than probing the depths of their psyche. This is not to say that psychiatry is somehow less important. But I went into the psychiatry rotation sure that I did not want to go into psychiatry, and I left the rotation 100% convinced of that. (The same was true of some other rotations, too.) But I will be the first to say that I appreciate the patients and attendings of the psychiatry service, because they definitely helped me improve my history-taking skills.

For example, one attending really focused on the nonverbal aspects of the patient encounter, like my distance from the patient, and my posture. This kind of thing really matters with psychiatric patients –- it can be the difference between a useless visit and a very helpful one. But the lesson applies more widely; all (conscious) patients take note of the nonverbal cues from their doctors, so body language is not just a psych-only concern. Plus, psychiatry plays a critical role in basically every discipline. I was talking to a general internist, and his comment about the psychiatry rotation was, “It may not be the most fun, but it was the most useful” of his third year rotations because he deals with psychiatric issues several times a day in his clinic.

So one day, that psychiatry attending sent me in to talk to a patient and see how he was doing. Since part of the trick to taking a history is being able to talk to anyone about any given condition, I didn’t know too much about him going into the visit. He was a middle-aged guy, neatly dressed and not obviously agitated, but as soon as I introduced myself he announced that he did not trust me, that he knew I would tell “everyone” what he told me. I assured him that I took both the laws and the moral principles involving confidentiality very seriously, but he dismissed that as “just words on paper.” Even so, I pushed ahead into a discussion, and through some careful, incremental questioning was able to get him to talk about what he did for a living. He hinted at some dark secret, and with some coaxing he told me that his previous job was sneaking into hospitals and disconnecting specific people from life support, for which he was well paid. Basically, he was claiming to be the world’s laziest hitman.

While the story is funny now, the important part of the history is to get the patient’s full story on their own terms, and there certainly isn’t anything funny about the genuine daily-life problems that this kind of person experiences. At this point I’d been taking histories in various situations for a year, and while I certainly don’t claim to be an expert, I was able to keep him focused and trusting enough to elicit his feelings about this job (he claimed to have no remorse; disconnecting people was “just business.”) So this was really interesting, not only because this was a strange kind of false idea he was creating, but we were getting to his feelings about these imagined events, which is important in pinning down a diagnosis and, hopefully, helping him recover.

Of course, I have very little idea of how to do that stuff, but I was happy that my job, the history, was at least going in the right direction. Just then, my attending knocked on the door and joined us. (One thing that was constantly true on psychiatry was that when patients wouldn’t open up, the short time I had seemed like an eternity, and when things were going well it seemed like only a couple of minutes before the history was over.)

At the end of the rotation I passed the shelf exam, which was mostly on the side effects of drugs and the aspects of personality disorders. But the day I gained the trust of the world’s laziest hitman was the day I knew I’d passed the most important practical test of that rotation -- taking a half-decent history when someone doesn’t even want you to.

May 12, 2008 in Ben Bryner | Permalink


Just wanted to ask... the patient that you promised confidentiality to, just ended up on a blog that will be read by people worldwide. Not that you ID'ed him by name, but how would he feel knowing that you are here talking about him after promising not to talk about him?

Posted by: renogirl | May 13, 2008 6:13:08 PM

All case studies are off patients which all docs promise confidentiality to!!

Posted by: | May 17, 2008 11:26:51 PM

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