A Junior Doctor’s First Impressions of Dementia.
Shifting paradigms and eclectic emotions.
‘Dementia is a chronic, irreversible disorder of brain function.’
‘Dementia is a major public health burden.’
‘Dementia detriments psychological wellbeing.’
Throughout medical school, various facts about dementia are flung into the maelstrom of our developing clinical brains. Although it is rarely a major focus of the teaching that we receive, its ubiquity amongst elderly patients gives it a certain ever-present aura. Furthermore, its mysterious aetiology and the painstaking search for curative treatments makes it a difficult subject to fully understand. Some of us may have had the misfortune of watching loved ones suffer from dementia. Witnessing the progressive decline of the powerful figureheads that featured so heavily in our childhood can be exceptionally difficult to stomach. Many of us, however, will have had little experience of dealing with dementia aside from vicariously reading a memory walk fundraiser post on our Instagram page.
I recently started my first job as a junior doctor. Emerging from the comfortable cocoon of wearing a bright red lanyard, equipped with the all-purpose ‘I’m just a medical student’ card, brings with it a number of mixed feelings of excitement and apprehension. My first job was on a geriatrics ward. These wards typically care for patients with an average age well over 80 years with never-ending drug charts and multiple co-morbidities. The complexity of their medical circumstances is compounded, dramatically, by cognitive issues such as dementia. Six years of medical education have developed our skills in clinical reasoning, communication and empathy. Each of these skills are tested to the limit when dealing with dementia.
Managing dementia, hands on, for the first time as a brand new junior doctor triggers a number of emotions.
Sadness is a fairly predictable and natural emotion that the mere concept of dementia would evoke in anyone. Patients who struggle to care for themselves and maintain the most basic of human dignities were once budding professionals with razor sharp intellect. They were top class sports people, adoring parents and mischievous children. The intensity of the sadness resulting from dementia is, perhaps, most prominent in those who are still at the early stages of the disease. The awareness of your mind gradually slipping out of your control bears an enormous psychological burden. Observing the startling contrast between what a patient once was and what they are now instills a macabre appreciation of the fragility of life.
Frustration creeps in as you begin to understand the challenges of working with patients with dementia. This frustration stems from the gnawing feeling that there is little that you can do to help in some cases. As cliché as it may be, many doctors are driven through a medical degree by the idyllic vision of using their knowledge and skills to see sick people get better. Working with patients with dementia, for whom modern medicine has nothing more to offer, can feel somewhat stifling to a young doctor.
FEAR…is without a doubt, the most prominent of emotions. Learning medicine is sort of like a prolonged out of body experience. We learn about cirrhosis in long-term alcoholics and forget we have a liver, we learn about infective endocarditis and forget we have a heart, we learn about interstitial lung disease and forget we have lungs. For most medical students (especially those of us who, through good fortune, are yet to require any prominent medical interventions), there is a strange disconnect between the diseases we study and the possibility that they could affect us or our loved ones. The arrogance and invincibility of youth is seriously tested when we encounter dementia. As I mentioned earlier, people with dementia were just like us for the majority of their lives. It may have happened to our grandparents. It could happen to our parents. It could happen to us.
As we step out of medical school and scan our shiny new ID cards through the automatic doors of our new wards, we are filled with zest and a burning desire to employ our knowledge to make a positive difference to our patients. A lot of proud rhetoric amongst new junior doctors revolves around our technical abilities.
‘I nailed a cannula!’.
‘I got to do a lumbar puncture yesterday!’.
‘I prescribed TB drugs for Pott’s disease!’.
Dementia brings us back down to earth. By disarming us as clinical interventionists, it makes us appreciate the humanness of our patients and it prevents us from facelessly pairing them with a Passmedicine question that we got wrong whilst revising for finals.
On my first day on the ward, I noticed that all patients with dementia had an ‘important things about me (ITAM)’ form. Filled in with the help of their loved ones, it is a one page summary of the patient’s interests used to comfort them with familiar conversation in an unsettling environment. In other words, it’s a bittersweet summary of the things that give them any quality of life. To all the able-bodied and able-minded readers out there, take a moment to think…
What would be on your ITAM form?
Written by Dr. Lasith Ranasinghe
