I received an email from a course candidate who failed her vignette section. This is one of the vignettes she believes she did not do well on. Let’s review and see what went wrong.
Psychiatry Part 2 Exam Vignette
One of my vignette cases was about a 30 year old female physician who was treating patients in an HIV clinic and became concerned about contracting germs. She began washing her hands and eventually had the whole floor cleaned every day with disinfectants. That was the essence of the case. I don’t remember the exact details.
My response was that this is OCD reaching delusional proportion. The examiner asked me how I would treat the patient. I don’t remember if I talked about the pharmacotherapy. But I talked about exposure and response prevention therapy which I explained to the examiner.
While I was explaining the Therapy steps, the examiner asked me if this doctor should be practicing. I answered that she should not be permitted to practice until she is fully treated and her insight and judgement into her behavior and symptoms improve. Even before I completed the sentence, the time was up. I think this is one of the vignnetes I failed.
Jack’s Response
The details in this case are limited. Despite that it strikes me that the main error the candidate made was in making diagnostic and management assumptions without first assessing the patient to confirm her initial suspicions.
1. First assess whether a psychiatric disorder is present. You must first establish whether this behavior was interfering with her function, was distressing, or time consuming (generally defined as taking more than one hour per day). That is not so clear in this case. Perhaps the physician was enforcing a cleaning policy that should have been carried out daily but wasn’t.
2. Second, assess the nature of the psychiatric disorder. I’m not clear there was enough evidence to suggest that the patient-physician obsessions were reaching delusional proportions. Obessions are often bizarre and debilitating and the person’s insight into them fluctuates. Thus, if the patient is under-assessed they can often appear delusional.
3. Third, you must assess whether this physician’s behavior was impairing her ability to provide patient care. Plenty of doctors have psychiatric disorders who continue to fulfill their patient care responsibilities. You have a responsibility to report a fellow physician who you believe to be providing inadequate or irresponsible care irrespective of the reasons.
So when the candidate was asked, for instance, if she would report this doctor, she could have said that would first evaluate whether the doctor’s behavior was compromising patient care. If in her judgment it was, then yes she would notify the department of professional regulation.
Today’s Life Tip: Pink Flamingo
One thing I’ve noticed about human nature (including my own) is that it is easy to avoid initiative. There are many, many people in this world who wish they had more friends, a better social life, and surrounded with greater community spirit. Yet, nothing to advance these wishes may take place. So they – we – wait and hope for the best. So here’s one of my favorite ideas as practiced in my neighborhood.
One of our neighbors started the tradition of placing a pink flamingo – those tacky plastic ones you can get in walmart of garden shops – on someone’s front lawn. Whoever has the pink flamingo hosts a Friday evening souree outside. The kids eat hot dogs. The adults drink beer or wine (or soda pop). The point is that it is easy, fun, and quick. It doesn’t require fancy sit down meals or a special occasion. When the weather is warm the neighbors get together.
Now, consider this. In every neighorhood there is someone who has to start this first. Someone has to take that small step, put him or herself on the line to go ring neighbor’s door bells – neighbors who may be strangers – to invite them over to a ‘pink flamingo get-together.’
Someone always has to be that hero. Will it be you?
Take care. Much love and success. I’m off today to The Strategium, our brand new conference. If you haven’t heard of it yet - you will. And you’re invited to the next one.
Jack Krasuski, MD
877-225-8384
