Today we had a standardized patient in small group: Two students interviewed the actor, occasionally calling for time-outs to ask the rest of us for advice. I spoke up twice when asked, both times about the same issue. But this issue seemed to only bother me and no one else, so after bringing it up one last time, I let it go. Tell me what you think:
Clinical scenario: 79 year old man requests sleeping pills from his internist. He can’t quantify his sleeping problems, just says “It seems like I could sleep more”. He has no activities, no interests, no friends. His wife of 50 years passed away last year after 14 years of illness where he was taking care of all of her daily needs. He had to quit his job to do this and now he does nothing all day. He says he hasn’t had a good day for 14 years and can’t remember what that’s even like.
I may not know anything about psychiatry, but to me it sounds like he’s depressed until proven otherwise. It just seems like a goal of the interview should be to determine whether he a) actually needs the sleeping pills, and b) is at risk for suicide. Even if we had just explored one of those topics, it would be something – but we didn’t explore either. I wanted to find out more about his sleep patterns, ask about suicidal thoughts, ask what he expected from the sleeping pills.
But apparently, that wasn’t the point. The point was that we were supposed to get practice talking to a geriatric patient about their personal history. So we didn’t talk about any of those issues – instead, we talked about suggestions for open-ended things to ask him like, “What was your wife like?”, “How did you feel when she died?” and “Tell me about your old business.” There’s nothing wrong with those questions – but I was hoping we’d use those questions to eventually go somewhere with the information, and we didn’t do that. It was incredibly frustrating.
I might be overly cynical here, but I really don’t feel like we need practice with asking open-ended questions. That’s not the hard part. In fact, I’m almost offended by the idea that we should be practicing a simple, non-focused conversation – I believe we’ve all proven we can do that at a previous event called “the interview to get into medical school.” I’m not saying we should be learning to screen for depression at this point, but as long as we were going to have this standardized patient and this particular scenario, the fact that we didn’t even address the issue of prescribing sleeping pills to someone who a) doesn’t need them and b) seems to also be severely depressed, if not possibly suicidal, is going to bother me for awhile.
Action Potential 
you are correct. but work him up for sleep apnea instead.
Wouldn’t it be great if medical educationists even once in a while listened to medical educationalees (I know that’s not a real word, but I (and my computer agrees with me) don’t think ‘educationalist’ is one either). I couldn’t stand ‘simulated patients’, although never underestimate the paucity of social skills some of your peers have. It’s frightening.
If it wasn’t before, it’s totally a word now. I like it!
Yes, sounds like depression to me. Anhedonia, possible sleep issues OR suicide issues or both should be enough to warrant further investigation. The anhedonia in particular should be a key concern.
But I think this problem of failure to recognise depression is not only true of students in training. I actually picked up the guts after 1.5 years of suffering to ask my doctor about depression and he just told me not to self-diagnose and proceeded to assert that sleep apnea was an 80-90% likely cause of my sleep and concentration problems.