What I wish I'd learned in med school

You might remember from medical school that psychiatrists use a five Axis system when evaluating patients. (Or at least they used to. The recent fifth edition of the Diagnostic and Statistical Manual of Mental Disorders eliminated the Axis system.)

Axis I refers to psychiatric pathology, such as major depressive disorder, bipolar disorder, or generalized anxiety disorder. Axis II refers to personality disorders, such as borderline personality disorder, narcissistic personality disorder, and obsessive-compulsive personality disorder. Axis III covers the medical conditions that the patient has. Axis IV, quite appropriately, lists social and environmental factors contributing to the pathology. Axis V is the global assessment of function.

This five Axis system at the very least reminds us that the individual is more than just the sum of his or her illnesses. Rather than existing in a vacuum, the individual interacts with the world. The system acknowledges that the individual influences the environment (through Axis V) and is influenced by it (Axis IV).

Though we are not psychiatrists, I do think that rheumatologists are generally attuned to the five Axis system anyway. We may not explicitly identify the axes, but we are most definitely interested in our patients’ level of function and how much support is available to them. We are familiar with depression and anxiety, and we don’t shy away from frank discussions with our patients about their emotional well-being.

But where I find my education lacking is in how to manage patients with Axis II (personality) disorders. And yet, I dare say, this is no less important than the other axes. At the very least, it affects my interaction with the patient.

For example, a patient with newly diagnosed rheumatoid arthritis who also has obsessive-compulsive personality disorder was extremely anxious and perseverated on his risk of lymphoma to the point of sleepless nights and frequent phone calls to me. There are patients with narcissistic personality disorder who feel entitled to special treatment and are unhappy even with standard care. Patients with histrionic personality disorder are emotionally labile and have a tendency toward hyperbole.

Most problematic for me are patients with borderline personality disorder. I meet one or two of them every year. By definition they split the world into absolutes, good and bad. They have a pathologic fear of being abandoned, so they heap you with praises that feel contrived and insincere, yet they will roll their eyeballs and speak disparagingly of your colleagues – mostly a bad sign. They are impulsive, argumentative, and frequently self-destructive. These traits make it difficult to manage their care appropriately, with challenges that run the gamut from potential patient noncompliance to exhausting physician goodwill. But they are patients, and we have a responsibility to provide them with the best possible care.

I envy the physician who can talk to these patients, address their concerns, gain their trust, and still be able to set boundaries and maintain objectivity. No one taught me how to do these things. No one even warned me that I would need to do these things. Truthfully, though, these are skills that cannot be taught effectively in a classroom setting. Rather, in this, as in many other situations, experience is the best teacher.

Dr. Chan practices rheumatology in Pawtucket, R.I.

You might remember from medical school that psychiatrists use a five Axis system when evaluating patients. (Or at least they used to. The recent fifth edition of the Diagnostic and Statistical Manual of Mental Disorders eliminated the Axis system.)

Axis I refers to psychiatric pathology, such as major depressive disorder, bipolar disorder, or generalized anxiety disorder. Axis II refers to personality disorders, such as borderline personality disorder, narcissistic personality disorder, and obsessive-compulsive personality disorder. Axis III covers the medical conditions that the patient has. Axis IV, quite appropriately, lists social and environmental factors contributing to the pathology. Axis V is the global assessment of function.

This five Axis system at the very least reminds us that the individual is more than just the sum of his or her illnesses. Rather than existing in a vacuum, the individual interacts with the world. The system acknowledges that the individual influences the environment (through Axis V) and is influenced by it (Axis IV).

Though we are not psychiatrists, I do think that rheumatologists are generally attuned to the five Axis system anyway. We may not explicitly identify the axes, but we are most definitely interested in our patients’ level of function and how much support is available to them. We are familiar with depression and anxiety, and we don’t shy away from frank discussions with our patients about their emotional well-being.

But where I find my education lacking is in how to manage patients with Axis II (personality) disorders. And yet, I dare say, this is no less important than the other axes. At the very least, it affects my interaction with the patient.

For example, a patient with newly diagnosed rheumatoid arthritis who also has obsessive-compulsive personality disorder was extremely anxious and perseverated on his risk of lymphoma to the point of sleepless nights and frequent phone calls to me. There are patients with narcissistic personality disorder who feel entitled to special treatment and are unhappy even with standard care. Patients with histrionic personality disorder are emotionally labile and have a tendency toward hyperbole.

Most problematic for me are patients with borderline personality disorder. I meet one or two of them every year. By definition they split the world into absolutes, good and bad. They have a pathologic fear of being abandoned, so they heap you with praises that feel contrived and insincere, yet they will roll their eyeballs and speak disparagingly of your colleagues – mostly a bad sign. They are impulsive, argumentative, and frequently self-destructive. These traits make it difficult to manage their care appropriately, with challenges that run the gamut from potential patient noncompliance to exhausting physician goodwill. But they are patients, and we have a responsibility to provide them with the best possible care.

I envy the physician who can talk to these patients, address their concerns, gain their trust, and still be able to set boundaries and maintain objectivity. No one taught me how to do these things. No one even warned me that I would need to do these things. Truthfully, though, these are skills that cannot be taught effectively in a classroom setting. Rather, in this, as in many other situations, experience is the best teacher.

Dr. Chan practices rheumatology in Pawtucket, R.I.

You might remember from medical school that psychiatrists use a five Axis system when evaluating patients. (Or at least they used to. The recent fifth edition of the Diagnostic and Statistical Manual of Mental Disorders eliminated the Axis system.)

Axis I refers to psychiatric pathology, such as major depressive disorder, bipolar disorder, or generalized anxiety disorder. Axis II refers to personality disorders, such as borderline personality disorder, narcissistic personality disorder, and obsessive-compulsive personality disorder. Axis III covers the medical conditions that the patient has. Axis IV, quite appropriately, lists social and environmental factors contributing to the pathology. Axis V is the global assessment of function.

This five Axis system at the very least reminds us that the individual is more than just the sum of his or her illnesses. Rather than existing in a vacuum, the individual interacts with the world. The system acknowledges that the individual influences the environment (through Axis V) and is influenced by it (Axis IV).

Though we are not psychiatrists, I do think that rheumatologists are generally attuned to the five Axis system anyway. We may not explicitly identify the axes, but we are most definitely interested in our patients’ level of function and how much support is available to them. We are familiar with depression and anxiety, and we don’t shy away from frank discussions with our patients about their emotional well-being.

But where I find my education lacking is in how to manage patients with Axis II (personality) disorders. And yet, I dare say, this is no less important than the other axes. At the very least, it affects my interaction with the patient.

For example, a patient with newly diagnosed rheumatoid arthritis who also has obsessive-compulsive personality disorder was extremely anxious and perseverated on his risk of lymphoma to the point of sleepless nights and frequent phone calls to me. There are patients with narcissistic personality disorder who feel entitled to special treatment and are unhappy even with standard care. Patients with histrionic personality disorder are emotionally labile and have a tendency toward hyperbole.

Most problematic for me are patients with borderline personality disorder. I meet one or two of them every year. By definition they split the world into absolutes, good and bad. They have a pathologic fear of being abandoned, so they heap you with praises that feel contrived and insincere, yet they will roll their eyeballs and speak disparagingly of your colleagues – mostly a bad sign. They are impulsive, argumentative, and frequently self-destructive. These traits make it difficult to manage their care appropriately, with challenges that run the gamut from potential patient noncompliance to exhausting physician goodwill. But they are patients, and we have a responsibility to provide them with the best possible care.

I envy the physician who can talk to these patients, address their concerns, gain their trust, and still be able to set boundaries and maintain objectivity. No one taught me how to do these things. No one even warned me that I would need to do these things. Truthfully, though, these are skills that cannot be taught effectively in a classroom setting. Rather, in this, as in many other situations, experience is the best teacher.

Dr. Chan practices rheumatology in Pawtucket, R.I.