My Hidden Curriculum

Ryan, Third Year Medical Student

So here’s the problem with 3rd year: I suddenly have so many stories to tell, but not nearly enough time to tell them! That said, the type of “busyness” that 3rd year has been providing is so, SO much better than what I experienced in the preclinical years.  Check this out, one of my patients turned out to be a widely published author; she gifted me one of her books:

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Pretty cool! I’ll probably reemphasize this notion throughout the year, but simply studying medicine is nothing compared to seeing it all come together in the clinic.  These experiences are all part of a “hidden curriculum” of sorts.  While tests still need to be taken and papers still need to be written in order to obtain a license, it’s the unofficial learning objectives I feel shape us med students into the doctors we are to become.  They may not be listed anywhere, but they are just as important.

Let me illustrate this with a short story.  After finishing my medicine rotation, I moved on to psychiatry.  Most psychiatric medical conditions are cared for in an outpatient setting, meaning the patient won’t stay overnight in a treatment facility.  However, when someone is sick enough to require hospitalization for a psychiatric emergency, this means that they are acutely a danger to themselves or to others. My rotation site was solely an inpatient setting, so all the patients I helped take care of fell into that second category of “danger to themselves” or “danger to others.”

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My Home for the Last 6 Weeks

While working on the adolescent unit in the Loma Linda University Behavioral Medical Center (LLU BMC), I found myself quickly growing frustrated at some of the situations I would encounter.  Not frustrated in an “I’m going to lose sleep over this” kind of way, but frustrated in the way I feel most doctors get when they wish they could change something, but know that it exceeds limits of how they could help.

Now, I realize that kids who have grown well in to their teens are fully capable of making their own decisions. But the thing that frustrated me about most of the patients I encountered is that most of the time, his or her psychiatric hospitalization was due to something beyond control. I’m not just talking about “bad genetics,” as is the case with patients who develop things like cancer or diabetes; I’m talking about things like poor decisions made by parents or abuse from peers.

So there I was, on the fourth day of my psychiatry rotation, when I met Craig*.  At first glance, he looked like your everyday average 14-year-old, but to the trained eye, one would have noticed his small sized head, flattened cheek bones, smooth upper lip, and other subtle facial abnormalities. Police had brought in Craig to the BMC after he had punched a family member multiple times for “annoying him.”  As a medical student, it was my job to talk to Craig and try to figure out why he needed a stay at the BMC and how we could help him.  This is done through the traditional process of interviewing to hear a patient’s story.

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Preparing to Take a History

Craig seemed like a nice enough boy, but shortly into the interview, I could tell something was not right.  He acted very embarrassed by the incident, claiming that it was “no big deal” and that he just wanted to go home.  When I carefully explained that he would not be able to leave until we were sure he was doing ok, he asked if he could instead visit with his girlfriend, who just happened to be living on the girl’s side of the same psychiatric unit. Surprised, I probed for more details about this girlfriend, but Craig suddenly changed subjects to talk about his 8-month-old daughter, who was already walking around and speaking in full sentences. He went on to tell me about his career as a rap star, how he was the captain and star running back of his school’s football team, even how he managed to single handedly subdue a drug dealer at gun-point.

After listening to Craig’s stories for about a ½ hour, I knew I would need to call his family for more information.  We ended the interview on a pleasant note, and I walked away trying to make sense of it all.  Though there’s always the slight possibility a patient is telling the truth when sharing elaborate stories such as these, there’s a good chance he or she is confabulating, and so extra information must be obtained from family (a process known as obtaining collateral). Confabulation refers to when a patient makes up memories or experiences, without intentionally trying to deceive. If you try to point out inconsistencies in these stories, the patient often becomes frustrated or defiant, insisting he or she is in the right.

I called up Craig’s primary caretaker, who turned out to be his first cousin.  The conversation began with Craig’s cousin answering various questions about his history, but quickly turned into a venting session as her own concern and frustration began to flow.  She explained that Craig’s behavior had always been highly unpredictable, and as he had grown bigger and stronger, this behavior had become increasingly disturbing and violent.  She listed some fairly horrific examples, including torture of animals, destruction of property, bullying other kids at school, and being a general terror around her home.

These examples made me instantly think of a diagnosis known as “conduct disorder,” but when I asked about Craig’s parents, a diagnosis didn’t seem as concrete. According to his cousin, Craig was the unwanted outcome of a one-night stand.  His mother used drugs heavily during her pregnancy, a pregnancy which was complicated by poor prenatal care and an improper delivery outside of a hospital.  The cousin said that after Craig’s birth, his mother wanted nothing to do with the child, so he was given up to his biological uncle, a man trying to raise 9 other children on a poor income. She explained that to help her uncle care for Craig, she watched over him during the school year.

At this point, I could tell Craig’s cousin was becoming tearful as the full gravity of her situation bore down on her. I attempted to provide some consoling words while reassuring her we would do everything we could to help Craig, ending the call. I took a deep breath as I tried to make sense of everything I had just heard, removing my glasses to rub the confusion out of my eyes. How could this have happened? What exactly was going on?

It was at that moment, my attending physician walked into our small workroom. Almost forgetting to say hello, I launched right into Craig’s story, hoping she could provide some insight.  She listened patiently as I recited back my presentation, glancing down at Craig’s chart every so often.

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Me with my Residents and Attending

“Well Ryan,” she began as I finished up, “this is an example of what happens when someone uses drugs during pregnancy.” She went on to explain how the frontal lobe of Craig’s brain, the area of the brain responsible for a person’s impulse control and personality, was likely severely under developed. Due to his exposure to drugs while he grew inside his mother’s womb, he couldn’t develop as in a normal pregnancy. This lack of impulse control lead him to do whatever tiny idea crept inside his head, set off by any kind of stimuli. If someone annoys him, he punches him or her. If a cat meows too loudly, he’ll throw it across the room. If he wants to plant a big sloppy kiss on a girl he passes at school, he’ll do it. “He lacks the basic control that you and I take for granted,” my attending said, finishing up her explanation, “he’ll struggle to live a normal life.”

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Brain Lobes!

As we discussed potential treatment options to help Craig control his impulses, I couldn’t help but feel so frustrated with the whole situation.  How is this fair? It’s not fair that Craig’s brain didn’t have the same chance to develop like mine did, it’s not fair that Craig’s cousin has had to live in fear of her own cousin’s impulses… it’s just not fair! And I don’t know the story of his biological mother, but what if she is the continuation of generations of drug abuse and abandonment? How is that fair to her?

Craig’s story is just one of many. I saw kids who were considering ending their own life because their parents called them “worthless” and “stupid.” I saw kids with terrible eating disorders because they were being bullied at school. I saw orphaned kids with no parents to teach them right and wrong, already so addicted to drugs it seemed like sobriety would only ever be a fantasy. And I saw kids who were terrified of other human beings because a family member abused them both sexually and physically. How is this fair?

As a Christian, I believe that sin runs rampant throughout the world, and that doesn’t seem very fair at all.  But I also believe there is a reason for this: God could have created us as mindless drones who loved Him by design, but instead, He gave us the gift of choice, something that makes our ability to love genuine, but something that has also resulted in consequences.

Whether you are religious or not, I believe that humans have a tremendous ability to love and care for those less fortunate.  There’s going to be a lot we see in life that “isn’t fair,” and we have to be able to accept this, showing compassion in spite of the circumstances.  And I’m not just talking about health care professionals; this applies to everyone!

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Fellow Classmates, Working Hard…

Rotating through the adolescent unit at the BMC has helped show me how to deal with these kinds of emotions, struggling with my natural inclination to defend the defenseless, yet show my concern in a professional and empathetic way.  As I mentioned at the beginning, this kind of training isn’t necessarily listed in a curriculum somewhere, but it’s experiences like these that provide the best teaching.  It’s definitely one of the things I’ll remember as I continue my education, hoping to touch the lives of others in a positive way.

Well, my psych rotation is ending this week, and even though it seems I was just there, I’m headed back to Kettering, OH for another short three weeks to complete my neurology rotation.  I was hoping to catch a Cincinnati Reds playoff game or two, but unfortunately for my poor team, they got eliminated in the first round (for the 3rd time in 4 years!).  I’m looking forward to seeing my family again, and maybe I’ll get to see the Bengals play instead haha. Until next time! (I feel like I need a catchy sign off phrase, any ideas?)

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My Wife & I in Oak Glen Over the Weekend

*Names have been changed to protect privacy.