Had to do a mock interview yesterday in front of my ICM group that involved telling my patient that he had chlamydia from this business trip fling with a coworker and the SP was insistent upon me telling his wife for him and I was like "Nope nope nope" and then he kept asking if he *had* to tell her, and I just wanted to yell, "Hell yes you do. She could get PID, become infertile, etc. b/c of your poor decision-making. So you had better tell her and she'd better get treated." But instead I calmly reminded him that it was his responsibility to tell her because her health could be at stake and that things would likely be worse if she found out later from her Ob/Gyn years from now rather than if he was simply honest with her. And then I referred him to a therapist and marriage counseling to work through their impending trust issues. My preceptors (one is a pediatrician and the other is a behavioral psych researcher) were happy with my interview, but one said that by law he didn't have to tell his wife and that I could have his wife come in with him and I could explain it to her. I found several things unsettling about this. 1) I thought he did legally have to tell her since doesn't that constitute bodily harm and or reckless endangerment or assault or something like that if you knowingly give someone an STI? I know they've successfully convicted people who were intentionally transmitting HIV but the malicious intent was clear there, so I imagine that's a more cut-and-dry case. 2) As a future physician, and especially as a med student, I am in no way qualified to be a relationship therapist--that is not what I'm trained to do. I can answer any medical questions they may have in terms of treatment etc. but it's not my job to inform her (unless he doesn't and in which case, confidentiality be damned b/c that woman needs to be treated). Further more, should he not prepare her beforehand regarding the reason for their visit, I'm liable to have an explosive and potentially dangerous confrontation occurring in my office. Doesn't that put me, my colleagues, and the other patients in harm's way? What do you all think? I really disagreed with my preceptors on this one. I don't think they were sending the right message to our small group either with their suggestions.
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With a tired sigh, Doctor Felix presses a red button on a tape recorder.
"Patient interview number two. Patient is known as Jinx." As he speaks, he scribbles onto some sheets on a clipboard, and the girl across the table can only picture doodles. He can't possibly be writing anything important, can he? "Interviewing Jinx is myself, Doctor Felix."
The patient in question bounces her legs up and down uneasily, uncomfortable with sitting still, uncomfortable with everything. The back of her neck itches, but her hands remain on the table, tapping away endlessly.
The doctor adjusts the glasses, pushing them up and looking to someone else in the room--a tall man, heavy set with an over-abundance of muscles, in a guard's uniform. No strangers to firearms, the city of Piltover had him set up with a hextech rifle of sorts, buzzing with a strangle electricity. Felix takes in a deep breath and continues, "After this morning's incident, she is required to be interviewed with a guard in the room at all times. In the room is Guard Charles."
The guard grunts in acknowledgement, offering no words. By the somewhat stunned and partially bothered expression on Felix's face, it's apparent that he had expected Charles to introduce himself at the very least. He brushes it off, however, and continues.
"Now, Jinx. Would you care to explain why you did what you did earlier?"
Rather than giving the rage-filled answer they had probably been expecting, she blows a raspberry, sending tiny flecks of spit toward Doctor Felix, which he dodges with his clipboard. He scribbles something down, and she scoffs at the action.
"What're you gonna write, Doc?" Jinx questions, crossing her arms over her chest. She shifts uncomfortably--the inmate uniform is scratchy and uncomfortable, and she isn't positive that she'll ever really adjust to the cheap material rubbing against her skin she otherwise would have left exposed. She dons a deeper voice, mocking the doctor, and says, "Ooh, the patient totally spit all over me!" and scoffs again.
Ignoring her words, Felix simply gives her a look as if to say, I'm listening, and waits for her to speak. Several moments pass before she groans and sits forward in her chair, leaning her elbows on the table in front of her. She thinks to take advantage of the freedom of mobility she's given when going to her interviews, since other times she may not have been granted that simple luxury.
"I was just walking down the hallway," she starts, "and wham! This idiot," she jerks a thumb at Charles, who narrows his eyes at her, "jabs me in the back!" Her head whips to the side to give the guard a dirty look, a look that craved vengeance, but the way it felt to turn... It all felt wrong. A hand finally flies to the back of her neck, and her fingertips, the nails cut too short to scratch, rub against the skin uncomfortably. Still, she adds, "With that stupid, lame gun!" Turning back to slam her open palms onto the table, she lets out an angered yell.
Taking his chance to interrupt, Felix asks, "And what did you do?"
Her expression darkening, she can't even muster a smile as she simply states, "I wrapped a braid right around his stupid neck."
He takes a few notes on this, leaving a moment of silence before continuing, "This has apparently resulted in some negative consequences for you. Would you like to tell me about one in particular that you dislike the most?"
Her other hand joins the other on the back of her neck, rubbing at the skin and continuing upward to run through her hair--aqua locks chopped short into an even and even objectively attractive bob. She pulls at the hair, letting her head dip forward as she rests her elbows on the table, tangling the bob into a mess.
There is a settling click of someone pressing play on a tape player, followed by a track of ambient static. Rhythmic metallic clicking rings against a hard surface in the background, something metal tapping against another object of some sort.
"Hey! Both our names end in X!"
"Yes, that's right. So, Jinx--"
"That's my name!"
"...Tell me about your weapons. I understand that you have names and personalities for them?"
"You bet I do!" she claims in excitement. The clicking noise--apparently the patient rocking in her chair--ceases with a clang. "See, the little one is Zapper. He talks too much, so I just sorta ignore him. I mean, he usually has good advice, like, zap that guy in the face! Or, zap that lady in the ass!" She groans and there's a slap of what's assumed to be her hand on a table. "But he's sooo annoying!"
"Right. And another?"
"There's Pow-Pow. You'd think he'd be a lot more fun, right? Pff, oh maaaan, he's a downer! But...he always agrees with me... So there's that!"
"I see. Now, how about the rocket launcher?"
"Pfft. Fishbones? What about 'im?"
"I've come to understand that he is the most responsible of the personalities you've created."
"Ugh. Why don't we talk about somethin' fun, doc?"
"What do you propose we talk about, then?"
"Hmm..." There is a brief moment of static-filled silence in the recording.
"Wanna hear a joke?"
"Alright," he states, quick and to the point. "Let's hear it."
"Weeell," she hesitates, and there's the sound of something being placed on some sort of surface--her arms, perhaps, "you might not like it. I mean..." There's a metallic scraping of what we now assume is the chair scooting its legs along the tile floor. "Alright, Doc. Why do cats have nine lives?"
You could just nearly hear the exasperation in the interviewer's voice, the patient grinding at his own patience, as he asks, "Why?"
The shift in her tone is almost sinister, yet still too amused as she says, "Makes 'em perfect for target practice!"
A shrill laughter pierces the recording, and in the middle of the shrieking noise, the recording ends with a click.
After all my hard times with these patients, perhaps now I have some bliss. Perhaps now things can be treated in a civilized manner. My patient today is Victor "Freeze" Fries. Otherwise known to the public, as Mister Freeze. I'm looking forward to this. Clearly not near as much as Joker. I feel I have a connection to Joker that I've yet to create with my other patients. None of my patients have ever behaved kindly to me like he. Perhaps Mister Freeze?
I exhaled slowly, hesitating to inhale the cold air, listening as the footsteps stop outside the door. After a few seconds of silence, the door slowly opened, and in Mister Freeze was pushed. He entered slowly and took his seat, looking at me with a cold, emotionless expression. It was hard not to pity him. In his empty gaze, he looked sad. No doubt he was. I understand where he's at right now. Losing a loved one. He lost Nora like I lost Guy... Though Nora has a chance of being alive. Guy's gone...
I shook the thought of Guy out of my mind, and smiled to Mister Freeze, before moving my hand forward to the tape recorder, turning it on. "Patient Interview number seven. Patient's name, Victor Fries, otherwise known as Mister Freeze. Hello Victor, I'm Dr. Harleen Quinzel, your temporary therapist. It's come to my understanding that I'm your therapist for today because your usual is home sick, with..." I look down at my clipboard, looking at the note I had jotted down about his usual psychiatrist, and accidentally giving a soft snicker. "...a cold... Your usual doctor is home sick with a cold..." I slowly pushed the smile away, confused why it was so hard for me to not laugh at it. Usually I'm more professional when interviewing but at the time I wasn't. I couldn't understand why.
"So Victor, when was the last time you attempted and/or succeeded in a break-out of the asylum?" Mister Freeze looked at me, almost angrily. "Today..." My eyes widened a little. "Oh... Today..." I looked back at him, a polite smile and my voice a little softer. "And how have you been feeling since returned to your cell? Why did you attempt escape in the first place?" He looked calmer as he explained. "I have Nora, my beautiful wife, hidden where I have been staying so she won't melt away and die. The television in my cell showed a news report. Nora has been found. Police are taking her from me. I had to get out and save her." I looked down, sadly, as I wrote notes. "You could wait it out in your cell. Wait until your time is up. Then go get your wife." Freeze looked at me, right in the eyes. He didn't look angry, but his gaze wasn't too kind. "If what happened to me, happened to you, would you want to wait it out in a cell? If your first true love were on the brink of dying, would you do everything you could to save them?"
My jaw dropped slightly, eyes nearly filling with tears as I looked down, thinking of Guy again. Thinking of him being on the brink of dying. Thinking of how I wanted to make him stop, but let him, because I loved him and he wanted me to. Because he wanted me to, to show that I really loved him. I wanted to stop him. I rubbed my eye, muttering silently. "Yeah... Yes, I would..."
I slowly reached my arm up to the tape recorder, shutting it off, sitting in silence as the guards came in and took my patient with them as they left.
Any patient interviewing tips? I'm having difficulty wording my questions to ask the appropriate questions in asking patients their symptoms. for example pain. I need to ask things like site, severity, quality, etc, but I just seem to always miss a few points. And sometimes I just get such a word block from being so nervous.
PRACTICE, PRACTICE, PRACTICE.
If real patients make you nervous, have your family members or friends play patient for you so you can work on your interviewing skills. These people know you well and will be able to read if you're too nervous. Ask them to critique you.
Before you go in to see a patient, you usually have at least their chief complaint available to you. So take a few seconds to think about that complaint. Come up with a quick differential and remind yourself of a few questions you want to be sure to ask.
Don't try to be fancy. Use simple terms. It will help you be less nervous and your patient understand you better.
As for remembering question about pain, stick with the same order every time. I used the OPQRST mnemonic in med school, which stands for Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, Time. Sometimes I'd even write the letters down on my little paper I used to take notes when I interviewed patients. I promise you, once you do it 50 times, you won't need a mnemonic. The same goes for any patient interviews, not just questions about pain. If you ask things in the same way every time, you don't have to come up with proper wording every time.
Remember to also start broad and open ended and then narrow your questions down.
Also as you're interviewing a patient, keep a differential diagnosis running in your head. If you're thinking their abdominal pain could be cholecystitis, appendicitis, peptic ulcer, GERD, pancreatitis, hernia, ovarian cyst, PID, diverticulitis, etc, then you can think of some other review of systems to ask them to help you narrow down your differential.
Example after the jump:
Patient presenting with abdominal pain.
"Tell me about your pain".
"It just hurts real bad all around my stomach"
"What were you doing when it started?"
"Just watching tv."
"What did you do before you sat down to watch tv?"
"I ate dinner. Pizza."
"Does anything make it better or worse?"
"Yeah, I can't eat anything. It is WAY worse after I eat. It only calms down if I don't eat. I tried Pepto, Tylenol, and my wife's Lortab, but they didn't help."
"What does the pain feel like?"
"I don't know man, it just hurts."
"Could you call it sharp or dull?"
"I guess it's dull all the time, but every so often I get this sharp pain-- no, more like a squeezing, that takes my breath away."
"Can you point with one finger where it hurts the most?"
"Right here is the worst, but the whole right upper side is bad."
"Does the pain move anywhere other than your belly?"
"yeah, this sounds kind of silly, but my right shoulder kind of hurts too."
"On a scale of 1-10, one being just annoying and 10 being the worst pain of your life, how would you rate it?"
"At least a 12".
"And did this pain just start tonight, or has it happened before?"
"it's been happening off and on for a while but just got this bad tonight."
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I sat in the same room as before. Where I had my interview with the Joker. But now, I would not be interviewing Joker. I had to admit I was slightly frightened. I wanted to interview Joker, not all the other baddies as well. But, today I would be interviewing yet another. I heard footsteps outside the door. Three people, it sounded like. One persons footsteps sounded bare. Like there was no shoes on their feet. As the door opened, I caught a whiff of something. It smelt like... Perfume. Why would an inmate smell like perfume? Shouldn't they not be granted the ability to have perfume in an insane asylum? The inmates could use it for... Heck, drug purposes!
In came Poison Ivy, who, with a blank expression, made her way to her own chair and sat down. Her back wasn't rested completely against the back of the chair, but rather it was twisted in a way where her left elbow was against the back of the chair, and her right leg was crossed over her left. She looked almost... lovingly toward a guard. "Dear, why don't you leave the doctor and I alone." The guards both spoke in monotone, with blank faces. "Yes, Ivy." They turned around and left, leaving Ivy, myself, and the odd perfume-like smell.
I sat calm, then spoke up after the guards left. "So I assume they were under your control?" Ivy turned her head to me, not changing her sitting position, which looked incredibly uncomfortable, but given her 'seductive persona', it made sense. "Oh darling, they've always been under my control. Men--that is. They just don't all know it yet." As Ivy spoke, I jotted down notes.
Guards were under her control
States that men are always under her control
What does that mean?
Why does it smell like perfume in here?
"They just don't know it? What do you mean?" Ivy gave a small smile, and a slight chuckle. "Men only want one thing, doctor. Men are always under my control because I make them believe they'll get it." "Now that's not true. Men want many different things." "But they all want a woman, too. Isn't that right? I bring out their innermost desires, and control them over it. It's my specialty." She tossed some hair out of her face, and changed her sitting position. She sat forward, leg still crossed. She spoke in a slow, hushed tone. "No man can resist me because of it." Her voice got lower, and much more slow and seductive. But along with that, I heard a hissing. Like... Like a soft, hissing echo. "Nor can a woman..." She gave a smile, and leaned back again.
The room was hot. The air was thick. I had a major headache, and I had to admit, Ivy was scaring me. So... Seductive. So... Feeling like she owns humans, like they're all her slaves. I quickly decided it was best to turn on the audio recorder. She wouldn't act quite like this when she's being recorded, when there's proof of how she's acting. I turned on the audio recorder. "Patient interview two. Patient Pamela Isely. Alias, Poison Ivy. Hello Pamela, I'd like to ask you some questions." She gave a smile. "Please doctor, call me Ivy." I nodded. "All right, Ivy. So, what is your motive behind what you do?" "Oh, world peace, of course." Ivy responded quickly. I was confused. "World peace? You have killer plants attack people, and it's for world peace?" Ivy gave a slight chuckle. "Well, mainly for peace for my children." "Children? You mean the plants?" "Why yes. My poor children. Taken by humans, killed, murdered!" Ivy's voice raised. It was apparent she noticed this, because her voice became soft and slow again.
"People underestimate us. My kind. Someday, we will rule again. And you humans..." She gave a slight chuckle, and was silent. I shut my eyes tightly, and my head went down. I grunted in pain. I had a massive headache. It was hard to breath. I heard Ivy chuckle again. "Poor, poor humans. You really don't stand much of a chance, do you?" Ivy got up, and walked towards me. I would've asked her to sit down so we could continue the session, but I was so dizzy. She grabbed my chin softly, and moved it up so I was facing her. My eyes slowly opened. "I recall you looking at me through my cell window not long ago. Why was that, doctor?" She gave a light laugh and let go of my chin, before turning around and taking a few steps off. "I was thinking about it. And I don't exactly appreciate the staring." She spun around. I was certain now she didn't like me. Her hair flung as she spun and faced me. Her voice had the hissing echo again, but much louder. "I don't understand why Joker wastes his time with you. He has a strange fixation on you, you know. I don't get it. You're just like the other doctors."
Two guards came in the door. They looked from me, to Ivy. "Ivy! What did you do to her?" Ivy's voice remained calm, but somehow still sounded very worried. "Where's Jonathon? Where's Isaac?!" I assumed those were the guards she came in with. A guard went behind her and grabbed both of her arms, yanking them behind her back to restrict her movement. She grunted, and looked back at him with a slightly angry expression. The other guard spoke in a stern tone. "They're hospitalized. Dr. Leland noticed something different about them, and realized your toxin scent on them." Ivy looked shocked, and the guard shoved her out the door. The other guard lifted me onto a stretcher, and took me down the hallway as the other guard dragged Ivy along. We went past Jokers cell, and I could just barely hear Joker shout to Ivy. "Pammy! Why'd you hurt the poor doctor?" Ivy grunted as the guard shoved her in her cell. "I almost did it for you, Joker! You wouldn't have had to deal with her." Just as I was being pushed out of the room, I heard Joker say "I don't plan to kill her--!", then I heard nothing in the room. I assume I had passed out, but I don't even remember.
I later went back to the room the interview took place in, after it had the air cleared. The recorder was still going, so I turned it off and put it back in my pocket. My head still hurts from the incident, but I feel much better.
But I'm mentioning CF today purely because it's the only one where we heard actual resentment towards the effect the disease has had on them. Rebelling by not taking 30 pills a day, going out and getting drunk and being normal and screwing the disease, we heard all about... but one of the guys mentioned that people say to him, "Well, you could get hit by a bus tomorrow" and his response is, "Only if I'm driving it." and mentioned how it trivialises his disease.
Which is true. I mean, I use the bus thing to justify everything that I do. But hearing him spit that response, actually show emotion, in a cohort that to this day has been built on detail upon detail upon endless detail that you cram into your head so you can study more... This is why we have the interviews.
One day, most of us will be treating real patients. And so, actually seeing that not-so-nice side, spoken with such passion, was so moving.
So even though I know they'll never see it, I'm going to thank Sean and Steve for speaking to us, for letting us in for an hour to their world :-)
