As a psychiatrist, I was trained to begin the mental status examination and overall assessment of my patient as soon as I greeted them in the waiting room. Even now, three decades after finishing medical school, I follow almost the same sequence of actions in my day-to-day interactions with my patients that I did as a resident in training. Granted, there are now electronic medical records and I rarely come in contact with a paper chart any more, temperatures are recorded with digital thermometers and blood pressures with self pumping cuffs, but a large part of the basic interaction between psychiatrist and patient has changed little since the days of Freud.
I greet my patient in the waiting areas of the clinics I work in, usually offering a handshake unless it is obvious to me that the person is painfully shy, obviously paranoid, or just has their hands jammed down into their pockets with no intention of bringing them out. I walk ahead of the patient at first, since I have to swipe a card to let us into the next hallway via an electronic door. After that, I usually offer to let the patient go first so that I may assess station, gait, arm swing, clothing, personal hygiene, balance, coordination, response to directions and a myriad other things that one can assess just by direct observation. It has always been interesting to me just how much I can know about a person before we even enter my office and sit down, before the first questions are even asked.
Now, I could bore you with a blow by blow of the next thirty minutes of a psychiatric appointment, but I won’t do that. What I do want to tell you about is one of the most fascinating parts of history taking in the psychiatric consultant’s room, something I have begun to pay much more attention to in the last few years.
“Mrs. Jones, let’s get you up on the scales so I can get your weight today before we sit down.”
Yes, the simple act of my patient stepping on the scales that are prominently positioned in my office before we do anything else is a treasure trove of information.
Now, watch and listen closely, because after I make that statement (and it is a statement, not a question), information about my patient starts to fly. I try to capture it all, either on paper (the actual height and weight themselves) or in my head (the hesitancy or willingness to get up there in the first place, for example).
“Should I take my boots off? These are steel-toed boots, and they weigh at least fifteen pounds.”
“Do you want me to take my clothes off?”
“I just weighed myself at home and I weighed …”
“Well, you know I just had a big lunch.”
“Well yeah, I know that’s ten pounds more than last time, but I always weigh myself naked at home first thing in the morning, so …”
“I’m big boned.”
“Aw, man, do I have to?”
“The nurse just weighed me last year.”
“I think this medication makes me sleep-eat.”
“I will if you will.”
“Wow, this is like going to a real doctor’s office!”
“Can’t you remember to weigh me before the Christmas holidays this year, instead of after?”
And of course, even as these statements are coming, there is the Sacrament of the Emptying of the Pockets, a ritual that virtually everyone I’ve ever weighed must religiously practice. It is second only to The Removal of the Heavy Shoes. What have I seen come out of the pockets of six year old children, adults in their thirties, and octogenarians?
Money, baseball cards, combs, gummy bears, marbles, pills, knives, a gun (once, and that was enough), condoms (that was the octogenarian, but the way), paper, rocks, scissors, cell phones of every size and variety, iPad minis, paperback books, CD players, bugs (usually in bottles for safe keeping), baseball caps, sunglasses, Tums, aspirin, Motrin, Tylenol, cough syrup, cigarettes, cigars, and chewing tobacco. Once, there was even a brick. Another story for another day.
Okay, we’re almost on the scales. Can you believe it? Now can you see how much I already know about you? We haven’t even started the formal interview yet!
Yes, there’s more.
If you are the kind of person who wants to show me how good you’ve been with your diet and exercise regimen, you don’t wait for me. You reach up and confidently push the little weights across the bars until they settle at the points you are sure they will settle at, since you weigh yourself five times a day at home. You are happy to show me how much you don’t weigh today.
If you are grossly overweight, you know it, I know it, and you know I know it, you also reach up and manipulate the mechanism. However, knowing that you weigh over three hundred pounds, you push the bottom marker to 200, and then you inch the top one along until it gets all the way to the end of the beam, hopeful that in the time it took us to reach my office from the waiting room, a metabolic miracle has occurred. The Immaculate Reduction is what you are praying for as you ascend the platform. Only then do you accept the fact that the lower marker must now go to 250, then we inch, inch, inch … yeah. Denial is not just a river in Egypt.
Finally, if you just can’t stand it when I act like a real doctor and demand these ridiculous vital signs of you when I should just stick to being a psychiatrist, after all, you get up on the Perch of Shame, but you face outwards, towards me. This accomplishes two things.
First, you may glare at me for putting you through this. Secondly, you don’t want to know. You don’t want to watch. You don’t want me to tell you.
“Well, Mrs. Jones, it looks like today you weigh …”
“Wait, wait, don’t tell me!” you exclaim, dreading the verdict.
“Okay, okay,” I say, as I pause mid-scribble, writing the figure on my note sheet for the visit.
“I forgot to take my keys out of my pocket!”
You drop a set of keys that looks like it could open every locked door in the state hospital plus gain access to a few dozen vehicles for good measure.
“Yeah, I should take off at least a pound for those,” I say, dryly.
A beaming smile lights up your face.
Our work is cut out for us, but we’ll make progress today, if we both pull our weight.
“Have a seat. Now, how have you been since I last saw you?”
Greg Smith is a psychiatrist who blogs at gregsmithmd.