On psychiatry in neurology

I walked into her room and gave her the spiel: “So, I can either word vomit everything I’ve read about you in the chart, and you can correct me as we go along, or you can tell me your story, which I’m sure you’ve done many times already.”

Most patients appreciate the out; they’ve spent the past 12hrs repeating the same story to the newest person to walk into the room. Most patients take me up on the chance to correct the young guy in the white coat and sit back as he tells them their own story.

The patient, M, declined and dove headfirst into her story.

Sudden onset of painless total vision loss in her left eye. As M got going, she picked up speed and began to flush: signs of autonomic activation and overall panic. I could tell she was getting revved up and I gently interrupted her by asking a new question, to slow the snowball roll of emotions.

She’s a mother of seven biological children. She’s also undergoing methadone therapy for prescription opioid use. She has fibromyalgia. And Lupus. Her past medical history paints a very unflattering picture to the jaded provider: she’s a complainer and will probably suck up your time. I will admit, I fell for this myself before walking in the room.

At a certain point, when discussing the vision loss, my question-based interruptions no longer held the emotions at bay. Emotionally revved, M began to tear up and catastrophize: imagining that she’s going to lose vision in both eyes and be a blind mother to seven kids while in her forties. How could she manage the household? How can she continue to make art?

I paused.

I asked M to take a breath.

I empathized with her, that this must be incredibly challenging and frightening, especially since we aren’t entirely sure what is causing the vision loss and if that cause is reversible. I told her that we needed to power through, I had more questions to ask about her history.

I didn’t tell her that I thought her crying was non-therapeutic, that she was freaking out and continuing down this road wouldn’t yield benefit on the other side. I felt her emotions spilling onto me: my heart began to pound and I felt my sense of cool withering under the weight of her anxiety. I had the sense that I was about to lose her and a sense of control over the interview, so I wrangled her back so I could finish gathering a decent history.

M agreed.

She told me about her meningioma history, how it has been scanned multiple times via MRI and CT. How she has been told it is stable. How she is worried that she should have done something in the past, despite neurologists telling her that she shouldn’t worry. Probably born with it and if it grows it will be managed.

On physical exam, M had total visual acuity loss of the left eye, except some acuity in the inferior nasal quadrant and preserved sense of light/dark in the other fields. Diminished reaction to visual threat on the L. Further, decreased sensation to light touch in all three branches of the L trigeminal nerve. All other neurological function intact.

I ended the physical exam with a sense of relief, that I could finally leave the room. I told her that I would return with the neurologist in a few hours. I asked her if she had any questions.

M said, “Beyond the obvious ‘why can’t I see out of my left eye?'” and smiled.

I smiled back and said fair enough.

I presented the patient’s history and physical to the neurologist.

When I finished, she asked me what I thought was going on. I told her that there is definitely some psych on board in this patient. The neurologist laughed and said okay, what else?

With some hesitation, I gave her the differential in my head: could be MS, if she has one autoimmune disorder she is more likely to have another, could be psychogenic, but unlikely given the presence of clear imaging that shows long-term and stable meningioma infiltration toward the optic nerve, and most likely related to the meningioma, given the history and the presentation with trigeminal nerve involvement.


We pulled up imaging and an MRI from earlier in the morning had been resulted. We scanned through and she gave a long exhale when we arrived at the level of the meningioma.

“That’s a big fucker.”

She has a large personality and a vicious wit. I like her. I rotated with this neurologist during my third year clerkship. My time on her service almost convinced me to pursue neurology over psychiatry. Almost.

“This is why I like strokes over the rest of neurology,” she tells me while leaning back in her chair. “With strokes, yeah there’s damage, but there’s a good chance that things will get better with the right treatment. Not all the way back to baseline, but at least there’s some hope for improvement.”

She points at the MRI images. “With shit like this? There’s nothing I can do for her. Neurosurgery won’t touch that. Maybe we’ll give her some radiation. But me? I’ll tell her that her vision is fucked and that I’m really sorry. It’s depressing.”

We walk into the room. M is laying in the bed, facing the window. The attending and I park ourselves on the windowsill, between the patient and the view.

The attending asks some questions in a soft, soothing voice. Very different from the gruff tone she uses with other providers. She treads lightly onto the subject of the visual loss. M sighs.

The attending cuts in, “I hear you are an artist. Can I see some of your work?”

M lights up. She opens up her phone and begins scrolling to find photos of her work. M begins to tell us with great excitement how she is self-taught, how her grandmother was a seamstress but refused to teach her. She describes the various mediums: crochet, needlepoint, jewelry, quilts, and so on. When she feels like she has mastered one medium, she begins another to keep learning.

We listen as she excitedly tells us all of this. After a few minutes, I can tell the attending is getting antsy, but doesn’t make any move to interrupt M or her joy. We make eye contact at one point, and I get the sense from the attending that this is the least we can do.

Eventually, M runs out of steam and begins to think about the visual loss again. And how she is afraid she won’t be able to make her art if she loses her vision in the other eye.

The attending asks if neurosurgery came by. Yes, and she has an appointment for the following day.

“Look, I’m really sorry this is happening to you. Unfortunately, there’s nothing that I can do. Neurosurgery is going to be your best option. I don’t know if your vision is going to come back in that left eye. We can, however, do our best to make sure that you keep your vision in the other eye. Because you got seven kids! And you make really cool art. We want to help you do that.”

She thanked us. I smiled at her. She smiled back. And then we walked out of the room.

She was discharged later that day. She saw our neurosurgery team. They referred her to a brain/eye surgeon in Philly.

I should’ve been more kind to her in that initial exam. She was panicking and I waved it away, stuck in the medical student mode of needing to present to my attending and that’s all.

I should’ve remained present in the room with her, instead of thinking about how to form a differential. I want to be a psychiatrist, after all. Shouldn’t I be more comfortable with that sense of panic?

Or maybe I’m comfortable with panic attacks and anxiety disorders, and less comfortable with true existential panic. The panic that arises from medical disorders and unexpected changes to health. I’m comfortable with psych patients and their neuroses, but a normal person experiencing an understandable distress due to their medical condition? That drives a chill up my spine.

And like a phobia, I simply need further exposure to this type of anxiety to remain calm in the face of it. Over the next four years of residency, I will gain that exposure. I’ll see many sick people experiencing this very human panic at their bodies failing them.

Can I stay in the room?

Can I ask the question that may open the floodgates?

Can I remain calm while those waves of emotion rush over me, and I have eight other consults waiting to be seen and written up?

Or will I take the easy way out: do what is required of me but not what I demand from myself?

We will see.

Over the next four years, we will see.

Long Form Sundays

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