Month: April 2011

The doors to the pet shop are open. Empty fish tanks are stacked near the entrance. Brightly colored fish that could never fit into any of the tanks are painted on the shop windows. Paper birds, all smaller than the painted fish, dangle from the ceiling.

Next door is a dental clinic. Blue scaffolding and nets obscure the windows. Two people wearing scrubs and holding clipboards stand next to the entrance. A woman pushing a simple baby stroller—holding only a quiet child, not a beverage or a heap of toys—stops, nods at the child, and asks one of them a question.

A man leans over the table he has set up on the sidewalk. He restacks the baby shoes that are teetering near the edge of his display. Belts dangle off of the table like parched leather tongues. A small cardboard sign advertises that all items cost two dollars each.

A city bus approaches the intersection and pulls away from the curb to make a right turn. Pedestrians in the street begin to jog: The bus has not slowed down. While turning, it passes within one foot of the people still in the crosswalk.

Across the street, 20-story brick buildings loom overhead. In each window is an air conditioner. Torn plastic bags, sheets of newspaper, empty beverage cups, and other detritus collects in the corners between the buildings and chain-link fences. Only the afternoon breeze visits the blue slides, green monkey bars, and yellow animal sculptures.

The kids are crowded in the ice cream shop, many looking at the menu affixed to the wall. Firehouse is the flavor of the month. The boys jostle each other; the girls point at the buckets of ice cream in the glass case. The city traffic drowns out their laughter.

Five of them exit the ice cream shop. Puberty has begun to play with their body shapes. Their school uniforms cannot hide this. One of them, a young man, looks over his shoulder and remarks to the group, “We’re in the ghetto. Downtown, that’s where all the white people are.”

I recently spoke with some people about medical systems—the actual processes involved in providing health care to patients. Story ideas involving systems sparked in my head: What about the guy who makes your sandwich at the deli? What if he had to grow the tomatoes? and cure the meats? and chop down trees to fashion the cutting boards? and weld the freezer parts together? etc.

All the ideas looked much better in my head than they did on the computer screen.

I then considered the systems that train physicians.

“Back when I was your age,” many pre-med students said that they wanted to become doctors so they could “help people”. They had the fantasy that they could help people with only their intellect, work ethic, and selflessness. Doctors, in this view, were self-contained healers that needed only their brains—and their brains alone—to solve medical mysteries.

This just isn’t true.

The path to a medical degree does little to dissuade this worldview. Students receive individual grades. Grades are often based on a “curve“, which can foster competition instead of cooperation among students. The Medical College Admission Test (MCAT) is an exam that doesn’t involve teamwork. The student sits in front of a computer. Alone. (“Back when I was your age, I had to fill out a Scantron sheet for the MCAT. Do you even know what a Scantron sheet is, kid?”)

To be fair, many medical schools now incorporate teamwork and group learning in the first year. Some students easily make the transition from striving alone to striving together; others struggle or frankly resist joining the group. Some fear that the group might dilute his brilliance (“regression towards the mean”); some lack patience to work with others; a few believe that they are always “right”.

Perhaps this resistance is developmentally appropriate. Pre-med and medical students must first learn the content of their studies. This requires individual concentration and dedication. As they progress through their education, they then learn the process of medical care. It doesn’t matter if you know that Streptococcus pneumoniae is the most common etiology of lobar pneumonia if you don’t know how to order a chest X-ray. (And what’s the best way to maximize the likelihood that the radiologist will read your film as soon as possible?)

With time and experience, medical students and resident physicians learn how the system does and does not work. Most physicians soon stumble upon this realization: You can have the best intentions to “help people”, but if the system blocks your efforts, it doesn’t matter what your intentions are. You won’t be able to help them. To do the work properly, physicians must rely on other people and systems.

To be clear, this does not mean that the intelligence and talents of the individual are trivial. A system arguably works “better” (more effectively? efficiently?) when it is comprised of smart, dedicated, and diligent people. The complexities and complications inherent in health care, however, demand the attention, care, and energy of more than one person.

All of us who work in medicine must constantly remind ourselves that we cannot provide health care by ourselves. We must explicitly teach this to our students. Physicians, in particular, must remember that “ancillary staff”—nurses, clerks, janitors, technicians, phlebotomists, scribes—help us in many ways that we take for granted. Without them, we could not do our work.

Psychiatry consult, returning a page,” she said, cradling the phone between her left ear and left shoulder. Digging around in her pockets, she eventually pulled out a half-sheet of paper that wasn’t already covered in barely legible writing and boxes marked with Xs. Her right hand clicked the pen and prepared to write.

“Hi, this is Cardiology,” the male voice on the phone said. Doctors tend to lose their names when they are calling consults. “Thanks for calling back. I could use your help.”

“Okay,” Psychiatry said.

“The patient’s name is Montgomery Ward,” Cardiology said. “He’s a 47 year old guy with a past history of high blood pressure, high cholesterol, and diabetes. He was admitted yesterday with a chief complaint of chest pain. We’re treating him in the coronary care unit for a heart attack.”

“Uh huh,” Psychiatry murmured, scribbling notes onto the scrap paper.

Cardiology took a breath and then said, “He didn’t sleep at all last night and won’t stop talking. He keeps asking to leave and says something about having to end the war overseas, that he’s the only person who can do it. I think he’s manic.”

“Huh,” Psychiatry said.

Cardiology asked for help with diagnosis and treatment. Psychiatry said she would see the patient within half an hour.

“Great,” Cardiology said. “Here’s my pager number, but I’ll probably be at the nurses station, charting.”

---

Psychiatry walked into the unit and immediately heard a man talking loudly. She guessed that this was Mr. Ward.

“If I don’t go there the war will never end I know the generals I taught them everything they know They will listen to me and stop They all know who I am The President will get upset if the hospital doesn’t let me go No one wants to make the President upset The President once gave me a golden heart—”

A nurse, recognizing Psychiatry, pointed at the talking man and commented, “He’s yours.”

Before Psychiatry could respond, a man in a long white coat and blue scrubs said, “Hey, are you Psychiatry?”

Psychiatry nodded.

“Hi, I’m Scott, the coronary care unit resident,” Cardiology said.

“Jennifer,” Psychiatry said, waving hello. “I’m guessing that’s Mr. Ward?”

“Yeah,” Scott said. “He’s been talking like that ever since he got here. He might have slept for an hour last night—if that. Let me introduce you.”

Scott led Jennifer into the room. He rolled a stool from the corner and sat down.

“Mr. Ward—”

“Dr. Scott, the President will be upset if you—”

“—I want to introduce you to Dr. Jennifer, who is a psychiatrist—”

“—don’t let me do my job The military is counting on me to be there and I have the secret codes—”

“Mr. Ward—”

“—and without the secret—”

“Mr. Ward!” Dr. Scott said loudly… and calmly. He waved his right hand in the air.

Mr. Ward stopped for a moment.

“I know you’re concerned about the war and your dedication is admirable,” Dr. Scott continued. “But I want you to meet Dr. Jennifer—”

“I once met a woman named Jennifer who said that she would help me get messages to and from the battlefields and she—”

“Mr. Ward,” Dr. Scott cut in, smiling. “Let me finish, please.”

“Sorry I just have so much to do—”

Dr. Jennifer watched the conversation and smiled to herself. Though he couldn’t finish a sentence, Dr. Scott was gracious with Mr. Ward. The patient was noticeably not put off with Dr. Scott’s interruptions. She was impressed. Not all doctors she had worked with in the past demonstrated this level of skill with patients—particularly those that were difficult to steer, for whatever reason.

“—so I hope you’ll talk with her so we can all help you get better soon,” Dr. Scott finished.

“Okay Dr. Scott whatever you say but the military needs me—”

“Hello, Mr. Ward,” Jennifer said, taking her cue. Scott stood up and Jennifer took his seat.

---

“… so that’s what I would recommend for you and your staff. Hopefully, that will help keep him here so he can get proper treatment,” Jennifer said to Scott. “I’ll put all of that in my note.”

“Thanks.”

“By the way,” Jennifer said, “you did an excellent job in there with Mr. Ward. Given his current state, it’s not easy to interview him. Nice work.”

Scott chuckled and looked down. “Thanks,” he said. “When I was in medical school, someone taught me how to talk to manic patients.”

“Oh, really?” Jennifer asked.

“Yeah. I was on my psychiatry rotation and the chief resident gave a talk on interviewing techniques. It was really useful.”

“And that’s why all medical students should go through a psychiatry rotation,” Jennifer said, smiling.

Before people descended into the subway station at 14th Street and 7th Avenue, they could hear his music. At the bottom of the cement steps was a man in a faded red shirt and jeans with tattered hems. The sticks in his hands made the steelpans sing. People slowed down and looked up as they approached him. Instead of a tropical melody, Elvis’s “Hound Dog” rang from the pans. A young woman with long brunette hair, a belted khaki raincoat, and a red umbrella stopped and watched him.

Up the steps and around the corner is a passageway to the subway station at 14th Street and 6th Avenue. At the boundary between the station and the long hallway was a man in a white dress shirt with short sleeves. A dark hat with fine pinstripes was on his head. His fingers strummed the thick strings of a double bass. Up close, the metallic buzzing of the strings hitting the bridge filled the air. Farther away, the deep melody became clear. His fingers moved quickly up and down the fingerboard as he looked around, unfazed with the crowds of people rushing past him.

Posters of female celebrities—Paris Hilton, Tori Amos, Aubrey O’Day; all Caucasian women—are plastered on the white tiles of the passageway. Two rivers of people, moving in opposite directions, flooded the corridor. In one, a man with stringy hair, large black-rimmed glasses, blue skinny jeans, and a red hoodie sweatshirt hurried past. He looked anxious. Behind him was another man with stringy hair, large tortoise shell-rimmed glasses, black skinny jeans, and a tight blue sweater. He was shorter than the first man. And behind him was another man with chunky hair, black-rimmed glasses, blue skinny jeans, and a patterned scarf tied loosely around his neck. He did not know that he completed the three of a kind.

A group of young women brushed past. One teetered by in five-inch heels. A black mini skirt looked as if it was painted on her curvy hips. Hoops nearly as large as her cheeks dangled from her ears. Her black hair swung into her face, momentarily obscuring her amber eyes and cocoa skin. She spoke Spanish to her two friends, who were also wearing high heels, dark rouge on their cheeks, and multiple shiny bangles on their wrists. They did not look at the posters on the walls.

At the end of the passageway, people wandered to the edge of the platform. Occasionally, the rumbling of a distant train echoed through the station. From underneath a set of stairs a drum set erupted:

BOOMBOOM chik! BOOMchik! BOOMBOOM chik! BOOMchik!

and then the bending and falling tones of a saxophone joined it. The melody scrambled over and under the beats; it was loose where the drums were tight. The drummer was looking straight ahead at a point a thousand miles away. The eyes of the saxophone player were closed.

Musicians, like others who create, must release the gifts flowing through them. Stampedes of stern New Yorkers impatiently trying to get home at the end of the workday will not stop them.

So what’s stopping you?

Your patient is a 32 year-old man with a diagnosis of schizophrenia. Six years ago, he heard commands from Christopher Columbus to “find the New World”. As a result, for six months he travelled to various cities in the country by Greyhound bus. In bus depots, he asked everyone he met to bring him to “Ferdinand and Isabella”. When he ran out of money, he walked along the shoulders of highways, praying loudly to God to save him. He slept little during his quest, as “the spirit is willing, but the flesh is weak”. Sometimes he heard the voice of God telling him to walk into traffic, “for [his] faith was so strong that [he] knew that God would stop the cars. In one of the cars a blessed saint would invite [him] in and guide [him] to the New World.” One day, he followed this command. The cars did not stop. No saints were driving that day. Several cars crashed and one hit him. Miraculously, he sustained only minor injuries.

He was sent to a psychiatric hospital for treatment. He eventually returned home to live with his parents, as he does now. They ensure that he attends his appointments, goes to the clubhouse, and takes his medications. He receives a supplemental security income check every month for his condition.

You’ve been working with him for about two years. He still reports hearing the voice of Christopher Columbus, but he has learned to ignore the calls to find the New World. Sometimes he wonders if cars would stop for him if he walked into the street, but he doesn’t actually try this. He occasionally expresses remorse that his faith wasn’t strong enough to prevent the car crashes that resulted in his hospitalization.

He cooks simple meals, reads books, tends to the plants at the clubhouse, and walks around the city. His parents report that he takes good care of their pet dog. He runs errands independently. He is punctual for his appointments with you and is invested in his health: He used to smoke a pack of cigarettes a day, but now has cut down to three cigarettes a day. To lose weight, he has stopped drinking soda. He got a pedometer and tries to walk 5000 steps daily.

Now, he comes to your office with a summons for jury duty.

“Can you write me a letter so I don’t have to go?” he asks.

Do you write the letter for him?

---

Some people—physicians or otherwise—react strongly to this question: “Of course I would write the letter for him. Do I really want a guy with schizophrenia serving on a jury? He hears voices, he’s tried to find ‘the New World’—do I really want a guy with that kind of judgment deciding the fate of another person?”

Some people—physicians or otherwise—think twice: “All citizens should participate in civic duty. If a jury consists of ‘peers’, aren’t people with psychiatric conditions ‘peers’? This guy has minimal psychiatric symptoms right now. And just because he hears voices—that he says he can ignore—doesn’t mean that he is incapable of assessing evidence and making fair judgments.”

The courts, rightfully or not, defer to physicians to determine if an individual is fit for jury service. The courts usually request a letter or affidavit from a licensed physician to attest to the individual’s physical or mental disability.

The literature has little to say on this topic. A search for “jury duty” on Pubmed returns only 21 results. A search for “jury service” returns 15 results. Several articles discuss how professionals may excuse themselves from jury service. One relevant article is entitled, “Is it right to exclude people with a mental illness from jury service?“, but I cannot access this British article. (Update: A medical student kindly sent me this article—thank you! Take home message in the UK: Someone receiving any treatment for a psychiatric condition cannot sit on a jury. If a person fails to disclose this, he can be fined.)

Hemmens et al. published an article in 1999 entitled, “The consequences of official labels: an examination of the rights lost by the mentally ill and mentally incompetent ten years later“. In this article, they review state laws related to jury service, voting, holding public office, marriage, and parenting. They state that, as of 1999, 38 states restricted those with a mental illness from serving on a jury. (This number increased over a decade.) They surmise: “A possible explanation for why the right to serve on a jury is so frequently restricted may be the recognition by legislators that immediate, irreparable harm can occur in the trial setting than at the ballot box or in public office.”

A search on Ovid shows several doctoral dissertations on the anxiety and stress associated with jury selection and service. As stress may contribute to psychiatric decompensation, one could argue that people with mental illness should not serve on juries. (“First, do no harm.”) However, people with or without psychiatric diagnoses can demonstrate extraordinary resilience. No one yet has shown that people with psychiatric conditions experience more stress while on jury duty than people without psychiatric conditions.

There are organizations, such as The Center for Reintegration, that argue that people with psychiatric conditions should be allowed to participate in jury duty. They argue that this can reduce the stigma associated with mental illness and facilitate reintegration into society.

Back to your hypothetical patient: Do you write the letter for him?

People often want to separate medicine from politics. This, however, is exactly how physicians can become agents of social control.