Some time ago, on a prior blog, I began transcribing some of my residency notes from my years at McLean Hospital and Massachusetts General Hospital in 1991-1994. A transfer of websites led to loss of the original blog posts, but here I will begin to rewrite parts of those notes. I plan to add to this blog post gradually, so that the notes are updated over time in this same post.
1993: At the Massachusetts General Hospital (MGH) Consultation/Liaison Program:
In the MGH consultation/liaison suite, where sat the offices of Drs. George Murray and Edwin (Ned) Cassem, both Jesuit priests and psychiatrists, there was a poster of a soldier in a beret standing unarmed, with the caption: “Your mind is your primary weapon.”
The program took a generally militaristic turn. We residents and fellows who rotated through it were called “psychiatric Marines.”
Another slogan on the wall stated: “No good deed goes unpunished.” When I asked someone what it meant, I was told that’s what happens with patients with borderline personality.
And then there was a last poster, the Standing Orders for Rogers’ Rangers, given by Major Robert Rangers in 1756:
- Don’t sleep beyond dawn. Dawn is when the French and Indians attack.
- Don’t stand up when the enemy’s coming against you. Kneel down, lie down, hide behind a tree.
- Don’t ever take a chance you don’t have to.
- Don’t forget nothing.”
These were our instructions as we went out to treat the psychiatric problems of a thousand patients in a huge general hospital.
Freud once said: In order for an interpretation to be useful, the patient has to be in the neighborhood of it.
Ned Cassem: Doubt is the shadow cast by faith.
Gandhi: Almost everything we do is insignificant, but it is important that we do it.
George Murray: What’s the difference between a man and a boy? A man’s toys are more expensive.
George Murray: The best way to describe the difference between men and women is to look at how they drive. When you’re stuck behind women in a car in a tunnel , they look at each other as they talk in the car, gesticulating, turning back and forth to the traffic and each other. Two men in a car just look straight ahead. The women are affectively engaged; the men are not.
Ted Stern, another CL psychiatry attending, liked to tell the “Frank Jones story” : “The Frank Jones Story is a 2-minute screening procedure proposed to measure problem solving by asking patients to explain an absurd proposition….’I have a friend, Frank Jones, whose feet are so big that he has to put his pants on by pulling them over his head.’ The story is told with no emotional expression exhibited by the clinician. Patients are rated on whether they showed an emotional response to the proposition, such as a smile, laugh, or disdain. Patients are then asked, ‘Can he do it?’ If patients correctly answer ‘No,’ they are then asked to explain ‘Why not?’”
Ted Stern differentiated the responses of people by whether they “git” it by showing an emotional response to the story, and whether they “get” by being to explain rationally why the story doesn’t make sense. There are four responses:
- Type I: Normal – they git and get it
- Type II: Delirium – they git but don’t get it
- Type III: Dementia – they don’t git or get it
- Type IV: Depression – They get but don’t git it
From rounds with Ned Cassem:
Uncommon manifestations of common things are far more common than uncommon things. (This comment was made in concluding that an older patient was more likely to have psychotic depression with unusual symptoms rather than temporal lobe epilepsy).
The whole is greater than the sum of its parts: A patient with mild anemia plus mild fever plus mild hypoglycemia plus a urinary tract infection has four mild problems; but put together, the patient will present as very sick.
Haloperidol has an anti-fear effect. When given to a 30 year-old woman after a car accident, he commented that she is afraid she will die, or be in the hospital a long time. A little Haldol can break the fear. It’s also useful in severe pain, unresponsive to opiates: fear causes pain.
A musician ran into Isaac Stern on a New York street. “Excuse me, sir,” he said, “how do you get to Carnegie Hall?” “Practice, practice, practice,” Stern replied.
George Murray: Think dirty! (In other words, pay attention to sexual aspects of patients’ problems).
