Thursday, August 31, 2006

The tin psychiatrist

He was a charming man, but an operator too smooth, greased from head to toe in the lubricant that runs the machine. On Tuesdays he played golf with local top executives at the most exclusive country clubs. Two other days a week, he dined with pharmaceutical representatives (only the most attractive female ones) at fancy restaurants. Psychiatrist by training and practice, he was also my mentor for some extra-curricular shadowing that I had arranged during my second year of medical school. Strictly speaking, he was more of a pharmacotherapist – he avoided psychotherapy as much as possible – his clinic patients had five minute appointments and he would squeeze in thirty patients per morning as this maximized efficiency and profits. He had the business of medicine all figured out.

Besides his clinic duties, our psychiatrist spent a fair amount of time in a downtown rehab center, and it was when I followed him there one afternoon that his behavior made a lasting impression upon me. He took me into his musty, oak furniture office, sat me down, and began to tell me briefly about two patients we were to interview that afternoon. He pulled out their files, shuffled some papers around, and then to my surprise picked up the tape recorder on his desk, flipped it on, and began dictating the first patient encounter. He sped through it, in sixty seconds documenting the patient’s appearance, mood, concerns, his assessment and plan, and everything else that belongs in a note for a thirty minute psychiatric patient visit.

This confused me--I was pretty sure we hadn’t seen the patients yet, unless he had already seen them during lunch before I arrived, yet he had talked to me about the patients as if we were going to see them together. Before I had a chance to ask, however, he was off dictating the second patient encounter. This one took all of seventy seconds, and by the end of it I had mustered up about all the courage that I could find.
“You dictate your notes before you see your patients?” I intoned as innocently as possible.
Looking at me for a brief second, he shrugged, “Yeah, I already know what they are going to tell me, it’s the same every time, and doing it this way helps me stay more organized.”
In afterthought, he added, “If anything turns out differently, I go back and change it.”
We proceeded to see the two patients, and as he had predicted, there were no major surprises.

Fast forward four years, and the other day I found myself writing a progress note for a patient using a computer template. She was a patient that I had taken care of all month who was no longer acutely ill and whom I knew very well, and I printed off the progress note in advance of seeing her, leaving blanks for the subjective findings. After seeing her, as I filled in my note, my eyes settled upon the physical exam section, which I had typed in earlier that morning, but which I could only now verify as being accurate. Remembering our dear psychiatrist, I shuddered and hastily scribbled in some additional physical findings.

Thank you, sir, for you were my teacher too.