The first part of the OSCE (I forget what that stands for) was for us to watch a video of a patient interview, and then write down everything we could think of on the topic. We had been told to be prepared to give the biological explanation for the disease, and any relevant imaging studies. 15 minutes before the test it struck me that there are only two diseases for which psychiatrists have a biological explanation (depression and schizophrenia), and only schizophrenia has any MRI evidence. So I quit studying all the drugs for depression and anxiety and bipolar, and stuck to the schizophrenia. And that was what the patient had. So that was really good. I put down everything I knew, including three random bonus facts that I had put in short-term memory when I decided to gamble on schizophrenia.

The second part was another video, only this time we had to make the presentation and treatment plan orally to a faculty member. The lady had depression, and some kind of personality issues. She kept repeating that she feared being abandoned by her husband or doctors, so I figured that fit the stereotype of borderline personality disorder. The doctor I reported to thought that was ridiculous. He explained that she clearly had dependent personality traits. And then he got so interested arguing about what personality she had that he forgot to ask about the biological theory and imaging studies (I had forgotten that the hippocampus changes somehow in severe depression). So I got a really good grade from him, because he forgot to ask about the things I didn’t know.

Afterwards we were all sitting around in a room, eating lunch and waiting for the multiple-choice test, and I asked everybody what personality they had said. Some people had said borderline, and different doctors had agreed; others had said narcissistic, or histrionic, or obsessive-compulsive, or avoidant – and everyone had found a faculty member to agree with these 6 different diagnoses! Doesn’t that tell you something? These doctors were diagnosing the exact same patient, based on the exact same video interview, with completely different personalities, based on how they imagined her inner story. One doctor imagined her as exaggerating her symptoms to get attention; one imagined her as so absorbed in caring for others that she had no inner identity; and so on. And she hadn’t said any of that! They all created a story for her, and then diagnosed it!

So I started explaining this to a couple of the students. 🙂 They demanded what I thought ought to be done with full-blown personality disorder, or depression (since I granted that full-blown schizophrenia and mania need medicines). I said, the best thing would be for the person to deal with forgiveness of past offenses, getting rid of bitterness, and stop being selfish. Who should guide this transformation? they asked. A Christian counselor.

At this point (while everyone else was nervously looking at the door and watching out for a faculty member to walk by) one of the two Muslim students in the room inquired politely what I thought ought to be done with non-Christians: “Is that going to be your main diagnosis? Axis I: Jewish, rule-out Muslim?” I laughed and said, Christianity is true and is therefore the best solution for anyone’s questions, but since I obviously couldn’t say that to a patient, I would advise them to talk with their own spiritual leaders. Somebody said, Are you serious? I went on, that since I believe in absolute truth, and Christianity, Judaism, and Islam all make exclusive truth claims, only one of them can be right. The Muslim students had to agree with that. It was about to get really interesting, but we had to go take the test. However, this group of 11 will be together for the next six weeks, too, so maybe we can pick it up again. This is my problem: Was I talking like that because it was true, or because I enjoy astonishing everyone and starting discussions? It was true, but was that the best way to say it?

Anyhow, the SHELF was ok. Lots of questions about OCD, as I had heard, but not much about childhood development, and fortunately nothing about psychotherapy, which is so silly that I just didn’t study it at all. A lot of the questions dealt with clinical decision making, the kind where I felt like saying, of course I would do all three of those things – how do I know which one to do first? Or picking one specific medicine or treatment plan, when I felt like saying, there are good arguments for all of those, it just depends on the idiosyncracies of your attending!

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