I.
I am not entirely sure how common it is to get so bored on vacation that you voluntarily return to your old workplace and accidentally start practicing medicine. Probably not very. But recently, thanks to certain flight disruptions in Dubai which I do not need to elaborate on, I found myself stranded at home in India far longer than anticipated.
I was going stir crazy. My parents, who maintain a baseline level of mild disappointment that I ever emigrated, suggested I go informally shadow the psychiatry department at my old hospital. "See what psychiatry is like at home," they said. "Maybe you will learn something."
I was already experiencing a profound disillusionment with psychiatric training in the UK, and my previous exposure to the Indian equivalent was highly idiosyncratic. During my internship at this same teaching hospital, my psych rotation had collided perfectly with the initial Covid lockdowns. Outpatient services were entirely shuttered. Any ward patient capable of bipedal locomotion was immediately discharged.
I spent those two weeks checking vitals in the female suicide ward and conversing with a very pleasant schizophrenic gentleman who had a hyper-specific obsession with light fixtures. He had been living on the ward for a decade (no next of kin and nowhere to send him after discharge except to the streets, and then the cops would drop him right back on our doorstep) and had somehow become a genuinely competent amateur electrician. I personally witnessed him replace multiple malfunctioning bulbs. He did very solid work.
So when my parents broached the idea of visiting, I agreed. It was mostly curiosity mixed with a bit of nostalgia. That intern year was almost certainly the worst year of my life, but people assure me this builds character. I thought it would be nice to show up as a glorified medical tourist and see what my Indian counterparts were up to.
II.
After pulling a few strings, I arrived at the outpatient department. It was exactly as crowded and poorly ventilated as I remembered, though stopping just short of actual asphyxiation. I located my point of contact, a second year postgraduate trainee, and optimized my posture to fit onto a partially vacant seat without crushing a colleague's purse.
The initial wave of patients presented with the classic poorly differentiated psychosomatic complaints that are the norm in developing countries. When your native language lacks a dedicated lexeme for "depression", psychological distress predictably routes itself through somatic channels. It manifests as a vague stomach ache or random peripheral tingling. We prescribed pregabalin, gabapentin, or amitriptyline, depending on mood, handwriting and the current phase of the moon. The patients were generally just thrilled to have seen a doctor at all.
Eventually, more interesting cases arrived. Because I was actively peering over my colleagues' shoulders, they generously suggested I take a crack at handling some of them myself. Sure, I thought. Why not?
I quickly came to regret this decision. I have a laundry list of complaints about British psychiatry, but I was not quite prepared for the reality of the Indian clinic.
First, the documentation varied from poor to completely nonexistent. My once finely honed ability to decrypt physician scribbles into valid pharmacological interventions had totally atrophied. Furthermore, the patients were terrible historians. I do not mean this as a moral failing; it is just a downstream consequence of local selection pressures. Government hospital care in India is free. This strongly selects for patients who are overwhelmingly poor, undereducated, and often separated from the physician by a formidable language barrier. Add the baseline communication difficulties of psychiatric patients, and taking a history feels like trying to reconstruct Herodotus from a copy that fell into a blender.
But it was a good challenge. I wanted to prove I could still read between the lines.
Almost immediately, I encountered a truly spectacular case of polypharmacy. We had a lady on lithium, valproate, and approximately a dozen overlapping medications. When were her lithium levels last checked? My best guess is shortly after the universe discovered helium-helium fusion. Thyroid function? The only confirmed fact was that she theoretically possessed a thyroid gland. She had coarse tremors, which could have been caused by literally any combination of the chemicals in her bloodstream. I consulted a senior resident, and we agreed to slash the regimen down to the bare minimum and demand some actual blood work before she returned.
III.
The cases only got weirder. Consider the medical tourist from Bangladesh. He had early onset schizophrenia, but he was relatively stable on his current regimen. Why had his parents brought him across an international border? They claimed they could not source brand name amisulpride in Bangladesh. A quick Google search suggested this was highly improbable, but here they were.
To make matters worse, the family was incredibly vague about his actual medication list. Besides his known antipsychotics and thyroxine, he apparently took a mysterious pill every morning. What was it for? They had no idea. What was it called? A mystery. What did it look like? It was a small tablet.
It is a miracle I did not tear my hair out. After another consult with the attending, we switched him to a more easily sourced variant of amisulpride and advised the family to stockpile six months of it before going home. As for the mystery pill, we essentially applied Chesterton's Fence to psychopharmacology. Chesterton's Pill was deemed structurally load bearing for this mixed metaphor. It clearly had not killed him yet, so we left it exactly as we found it.
My final patient was a six year old boy. His mother presented a constellation of complaints: he was hyperactive, liked staying up late, and lacked focus in class. It looked like a textbook case of ADHD. But given his age, I thought it was worth digging deeper. I learned he was functionally illiterate, possibly dyslexic, and his teacher had explicitly told the mother to get him evaluated.
Then the mother casually mentioned his "fright."
During normal daily activities, the boy would suddenly freeze. He would look incredibly distressed, and then he would get the human equivalent of the zoomies. He would sprint around the room. After the running stopped, he would approach his mother or older sister and bite them. Sometimes he bit hard enough to draw blood. He could not explain why he did this or what he experienced during the episodes.
I looked at him again. He was a perfectly normal, fidgety kid missing a few baby teeth. There were no obvious signs of hydrophobia, though I mentally filed rabies under "highly unlikely but technically possible."
I had absolutely no idea what I was looking at. I debated the case with a colleague. I suggested ADHD comorbid with Oppositional Defiant Disorder. My colleague argued against ODD because the kid was perfectly well behaved in the clinic. I countered that ODD typically manifests at home first, and is usually restricted to familiar adults. Then I floated the idea that his bizarre running and biting episodes might be complex partial seizures.
My colleague theorized it was an intellectual disability or learning disorder, perhaps part of a broader genetic syndrome. I shrugged. He was probably right. There might be a perfectly neat clinical label for this waiting in a dusty textbook somewhere. Or perhaps this is just another reminder that our diagnostic categories do not actually carve reality at its joints.
We eventually compromised. We prescribed clonidine to manage the behavioral symptoms and cover ADHD to a limited extent, then referred them to a clinical psychologist and an ENT specialist for good measure. I had spent more time on this one child than on my previous three patients combined, and the clinic was simply not built for that level of investigation.
I still have no idea what was actually wrong with him.
To avoid ending on a downer, I was happy to hear that the amateur electrician had, in fact, been discharged sometime in the past five years. None of the current trainees had heard of him. Right after I'd "treated" him? I'll take the credit, if no one's looking.
My parents, for what it's worth, were pleased I'd made myself useful. They remain cautiously optimistic about my eventual return.
I remain unconvinced, but I did find the pace to be California Rocket Fuel compared to my usual fare. Who knows? Maybe I'll get bored of making ten times the money, one day.
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Notes -
The following meant as a genuine question to a professional, not a combative gotcha:
Of all diagnoses that look like they're made up, ODD is the one that has always sounded the most outrageously made-up to me. What do you mean, "not obeying your parents" is classified as a mental illness? Activists who claim that the mental healthcare system is just a tool of state oppression usually come across as hopeless idealists who've never had a schizophrenic try to chew their face off, or indeed, never been a mortified schizophrenic returning to sanity after a try-to-chew-people's-faces-off episode. But on the face of it, the existence of ODD as a condition real doctors take seriously seems like exactly what you would expect if their model of psychiatry was correct. It looks so ludicrously like a gerrymandered way for parents and medical professionals to pathologize and thus de-legitimize the behavior of a lucid but uncooperative patient, for their own convenience or indeed revenge.
So I guess what I'm asking is: do you think a real case of ODD looks more like your Bangladeshi young man who occasionally flips out and bites his family members for no reason, while getting along with them the rest of the time and having no coherent complaint against them? Is that what it's supposed to look like, and thus, the reason why non-obviously-corrupt doctors take it seriously as a diagnosis? It doesn't sound like it, since you weren't sure about the diagnosis in this case. But if not, what is a perfect platonic case of ODD supposed to look like, and how do you distinguish it from a perfectly sane kid who dislikes their authority figures (or authority figures in general)?
Thank you for clarifying, and I'm not being sarcastic. While 99% of the medical professionals who reviewed my post had nothing but praise, there were two pedants and hostile interlocutors who ticked me off. One was a British doctor, who claimed he had studied in India, and accused me of gross clinical negligence, sneering at patients and colleagues for being "beneath me", and went as to far as go claim that I was a med student making things up using an LLM. I had a few choice words for him, but I am pleased to say actual verified psychiatrists are not that picky.
I do not have a very strong opinion on ODD. Mostly because I haven't done an official placement in child psychiatry, this example was literally the first time I tried reviewing an actual small child.
But I do share some degree of skepticism. However, from a pragmatic perspective, I think the diagnosis is fine. Scott has written about this, and I have little to add, but the gist of it is that the purpose of a diagnosis and clinical label is both to identify a "disease", and also to make getting care and intervention significantly easier. Sometimes the latter is more important to the patient or their family. At least it usually gets things covered by insurance.
It is difficult to distinguish between a child with ODD and one that is a petulant asshole. I am not even 100% confident that there's a qualitative difference.
But like the usual example of ADHD, many mental illnesses exist on a spectra, overlapping with the "normal" range. Is someone with a blood pressure of exactly 139/89 (on repeated tests) hypertensive? Not by the definition interpreted maximally strictly and literally, but half the reason we keep doctors around is to exercise clinical judgment and to rely on their discretion. I'd give him a pill to reduce the pressure.
Many cases of ODD age into the similar but technically distinct Conduct Disorder, and many later get diagnosed with Antisocial Personality Disorder, usually when they're old enough to qualify. Referring to my exam notes on Forensic Psychiatry, about half (!) of male prisoners in the UK have ASPD.
Clearly the diagnosis is identifying something. It just isn't as clearcut as we'd wish.
That's not enough. It has to be very unusual and disproportionately bad, by the reference frame of other children of similar age. A 2 yo throwing a tantrum wouldn't count. A 7 yo who refuses to listen to his parents, doesn't respond to punishment, keeps acting out in serious ways? Much more defensible, even if it's a question of degree and not kind.
An ODD diagnosis then, will help with getting psychological help, and very rarely medication (but mostly to treat the very common comorbidities like ADHD).
You are correct it wouldn't be typical. As I note, I am green when it comes to child psychiatry, most of my knowledge is theoretical. In clinic, I thought of it more as a could-be, with non-negligible probability worth excluding, instead of a very likely.
The child will very likely get multiple diagnosis, and even if there does turn out to be epilepsy, there might be other factors at play. I don't think a single disease can suffice.
Then there's the possibility of ID, which very commonly has behavioral issues. If there is ID, it might not be worth an additional diagnosis. Without opening the DSM or ICD, I can't tell you whether a diagnosis of ID would rule out ODD, I think probably. To help explain, when a person with dementia hears voices or feels depressed, we usually do not slap on a diagnosis of schizophrenia at 85 or MDD. Such signs and symptoms are very common in dementia itself, and we use a broader umbrella term called BPSD, but we still do use antipsychotics and antidepressants to treat it.
In other words, a wash. You can make a defensible argument either way.
I am out of my comfort zone, and I won't be lazy and ask ChatGPT because you clearly want my entirely human opinion (in reality, I would be asking ChatGPT myself, it's handy). Perhaps @reo might have something to add, he knows a lot more than I do. Maybe @Throwaway05 even if his OPSEC is so strong and his knowledge base so broad that he could be in anything from IMT to psychiatry to an ER specialist to a dermatologist. Maybe I could ask my peers in India, but ODD is rarely diagnosed here, certainly not as much as in the West.
Or I could ask ChatGPT and interpret the answer for you, it's genuinely up to you. And thank you for the question, it's a good one. I regularly have such doubts myself, for example whether BPD and the new diagnosis of cPTSD are meaningfully different.
Listen nobody here wants me to bitch about the decline in surgical skills training driven by laparoscopic and robotic surgery. It is poorly received every time! Every time!
So we talk about this psych bullshit instead because it is interesting and has more relevance to the average person.
For you-
I'm 110% not a child psychiatric and I did not examine this patient but weird behavioral stuff is usually Autism or ID in the U.S. The need to rule out some medical pathology is of course important (and obviously needs to be done with any patient with a presumed psychiatric diagnosis). That said this is a distant ass culture from mine and I'd have questions about how these things do and don't manifest in those culture. India strikes me as a place that would have a ton of variety and not variety in cultural presentation that would require a steady hand and clear eye to notice and distinguish with the other pressures (ex: time, resources) in play.
For OP-
You are hitting on one of those questions that is super valid and at the same time once you have training you forget it is valid. No shit "don't pathologize the normal human experience" is wise lol. It's very much baked into how the DSM thinks about things but beyond that too - being six foot four is more or less normal being seven foot four will have tremendous impact on your health, life expectancy, and experience of existence. But sometimes we forget this is an actual thing people worry about
Also, things like ODD exist to be like the pornography of psychiatry - give some labels and descriptions to "I know it when I see it" stuff.
Kids being difficult is normal. Some kids are "holy shit."
One of the ways to tackle this is by focusing on appearance in a number of environments. Kid acts like a bored little shit in church and school? Yeah fair. You leave em to their own devices at home and they also can't function? More likely to be pathology.
The real world does get in the way sometimes with overly dictatorial parents, attempts to get school accommodations, teens and adults relying on TikTok for stuff - but there is a real phenomena being targeted here.
Additionally, psychiatry is a bit looser than medicine - ADHD symptoms can be best explained by Anxiety, Depression, latent Bipolar disorder, medical illness, permanent brain damage, resolvable brain damage upon further development, substances, specific environmental factors, disordered personality.
Try sorting this shit out in a 15 minute appointment with a patient or family who already "knows" what the diagnosis is. Giving the diagnosis triggers further resources (including medicine) but doesn't always mean an understanding of the underlying mechanisms.
In the U.S. we shuttle things from Psychiatry to Neurology once we understand them (schizophrenia used to be early onset dementia, then we figured out what dementia was and punted it over). If something is still a psychiatric problem it means it is quite a bit more tenuous and complicated than a nevus or blood pressure evaluation.
Hey, don't be so harsh. You do have an audience for that diatribe, even if it might just be me. Let it all out, I have a father who I cannot accuse of lacking surgical skills even if his expertise is in laparoscopic surgery (and he is world-class at it, if I say so myself). This is a safe space.
Thank you for taking the time to indulge both of us. I am relieved to not be accused of being too wrong.
Among the many things I've seen that I've neglected to write up so far, was a patient who came to us that day with vertigo and double vision. She clearly had strabismus, as I could tell when I made eye contact (singular). No, there were no psychiatric symptoms, even after questioning. The people who accept and direct new patients to the relevant clinic are less than perfectly reliable, and that is without getting into some of the very questionable referrals I personally observed. We sent her off to neuromedicine, medicine and ENT, they deserve a taste of their own medicine. They've done much worse.
It's a travesty! Junior attendings lack effective experience! Nobody has experience with disaster cases! Open conversions are always in the worst circumstances! Hundreds to thousands of hours of extra training time!
Ultimately the switch is a good thing but it causes some skills deficits which are especially problematic in the US with the way our training works.
My favorite for this is autoimmune encephalitis, seldom seen, often missed, never fails to make the psychiatrist feel like the smartest person in the world and everyone else feel like a dumbass.
Boo. I genuinely was looking forward to a longer, more detailed polemic! I am zooted on stimulants, and not in a mood to study, so medicine-adjacent cognition is a good way to fool myself that I'm doing something productive.
I will note I have never heard another surgeon say this, at least in India, and I know more surgeons than can fit in a large OR. At least while maintaining aseptic conditions.
Then again, specific laparoscopic training is not a core part of the surgical curriculum, from my understanding. I have had my own seniors approach me, asking for my dad's number so they could ask him to teach them laparoscopic surgery with proper depth. He is somewhat famous for being a good, albeit short tempered teacher. My dad tried teaching me too, though all I can say is that I didn't drop the camera or cut off anything too important.
(He also taught himself laparoscopic surgery using a textbook, sometime in the 90s. Once again, deadly serious. He was a pioneer in these parts. I am but an ant in comparison.)
I would agree with you, if I had ever seen a case of autoimmune encephalitis. Best I've got is a genuinely unresolved case provisionally (so long it became permanent) diagnosed as extremely treatment resistant schizophrenia, where we excluded it and half of WebMD as differentials. My boss had to book a private plane to send him to the only ward in the country that would take him, this is not a joke or exaggeration. This is in the UK, and the government paid for all of it. I'm sure you're jealous, I hope you're jealous, give me one reason to not desperately wish I was in your place :(
(I will take a concession that you wish you didn't have to worry about insurance)
Basically the issue is that the required case volume to become proficient in modern surgical modalities is a lot more than with classic open cases. Decent surgical residencies can theoretically get you enough cases for bread and butter procedures but for less common things it gets harder. Consider how much harder it is to orient and to appreciate anatomy through a lap, and with a lap to ably use your technical skills (less of a problem with robots).
Surgical residency is already long and miserable enough, adding more years just isn't feasible.
Additionally things don't go wrong enough, which is good, but you need experience with things going wrong in a controlled environment to be able to provide quality care when you are on your own.
This means that many junior attendings aren't really fit for purpose and need hand holding, academic work, or enhanced engagement from their partners. None of which is good and it isn't really a solvable problem, especially with the push to condense training.
Also, usually the intern year for surgery is wasted on floor monkeying only pretty much.
Thank you for elaborating, I'm appreciative.
Ah. So this is universal, speaking from experience in the UK and India. I've heard even other postgrad trainees (in the UK) make the same complaint.
alarms blare
You've activated my attending trap card. Basic intern year scut work (both inside surgery and outside of it) isn't actually wasted. You learn valuable tools like "writing that fucking note quickly" and "nurse management" and "sick vs. not sick."
Certainly the modality has some yield issues at times, but the gain in fluency and skillset is real, with variable spaced repetition of more traditional surgical skills.
Also is what separates us from midlevels.
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