Nonfiction NYC

East vs. West: So Serious!

When I was a medical student in California, many of my classmates expressed relief that we weren’t in a medical school on the East Coast.

“Everyone is so serious over there,” they said.

The stories we heard about medicine back East!

  • “The medical students have to give all of their patient presentations from memory during rounds!”
  • “You have to wear a coat and jacket all the time! It doesn’t matter if you are on call! You change into scrubs after 9:00pm and then, before rounds in the morning, you clean up and put your suit back on! The attendings never see medical students or residents in scrubs!”
  • “If attendings ask you a question you can’t answer, they throw you out of (rounds, the operating room, the cafeteria)! They scream things like, ‘DON’T COME BACK UNTIL YOU KNOW THE ANSWER!!!’”
  • “They have to keep their white coats buttoned all the time! ALL THE TIME!”

These stories must have trickled down from the interns and residents who attended medical schools on the East Coast. Funny, though: I did not hear these tales directly from them.

During my surgery rotation, one of my residents attended a medical school in New York City. This surgery resident had olive skin, dark brown hair, and manicured fingernails. He smiled only once during the month-long rotation.

“Medical students don’t have any respect for the attendings here,” he once complained to the chief resident. The chief was a young man who was almost bald, had grey-purple bags under his eyes, and always carried a travel mug full of coffee.

“Back where I went to medical school,” the resident continued, “everyone called the attending surgeon ‘sir’. We all stood up when an attending walked into the room. If the attending asked us a question, we always finished our sentences with ‘sir’. You only spoke when you were spoken to. And our white coats were always buttoned.”

My classmates and I shot knowing glances at each other.

We then shoved our presentation notes for rounds into the pockets of our short white coats that were hanging open over our green scrubs.

During my time in New York City, I rotated through three different hospitals as a fellow. I visited many wards as the roving consult psychiatrist: I noticed the internists rounding in the hallway, saw the obstetricians rushing to labor and delivery, observed the surgeons dashing down the stairs, peeked at the radiologists staring at films on computer screens, spotted the pediatricians cooing at toddlers, and glanced at the internists still rounding two hours later.

From my observations at these three hospitals in New York City, I can say the following with confidence:

  • The medical students do not give presentations from memory. They read from their notes. Their voices are infused with anxiety and self-doubt. They are just as nervous as medical students out West.
  • I never saw any medical student, intern, or resident wearing a suit. If they were post-call, they were wandering around in their wrinkled scrubs and sneakers. If they were not on call, many men did not wear neckties! The occasional attending would wear a suit to work, but that was an uncommon sight.
  • Though I saw many floundering medical students, I never witnessed an attending throw a student out of rounds or the cafeteria. (I can’t comment about the operating room.)
  • Many physicians, regardless of their position in the hierarchy, did not button their white coats.

Nonetheless, I do believe medical training and medicine is more formal on the East Coast. More to follow.


Decisional Capacity (I).

Shadowfax presents a case study in applied ethics and asks:

What would you do if you were the doctor in this situation (or the administrator/ethicist/judge called to offer guidance)? Would you provide supportive care and allow him to die, or would you violate his express wishes and intubate him?

Physicians often call psychiatrists for consultation in similar, though less acute, clinical situations. These requests are called “assessments of decisional capacity”. Psychiatrists do not have a special license to make these assessments. Any physician can make a determination of decisional capacity. Many doctors ask psychiatrists to perform these assessments, however, as (1) psychiatric conditions can affect a patient’s decisional capacity and (2) psychiatrists have more experience than other physicians in assessing decisional capacity.

“Decisional capacity” refers to a person’s ability to make a decision for a specific clinical issue. This issue is usually related to treatment. After assessment, physicians can opine whether someone possesses or lacks decisional capacity for something specific:

  • “He has the decisional capacity to refuse treatment for his prostate cancer.”
  • “She does not have the decisional capacity to refuse surgery for her infected leg.”

“Competency”, which is often conflated with “capacity”, is a legal term. Only judges in courts of law have the power to deem someone “incompetent” and thus unable to make decisions for themselves.

Appelbaum and Grisso published an important paper that provides a four-point rubric to assess decisional capacity. (At only four pages, it is a short, high-yield article.) Most psychiatrists apply this rubric when assessing decisional capacity in medical settings. If the patient cannot fulfill any one of the four criteria, the patient probably lacks decisional capacity. As an exercise, let’s apply these criteria to the case that Shadowfax presents.

The question: Does the patient have the decisional capacity to refuse intubation and mechanical ventilation for treatment of his lung injuries?

1. Can the patient communicate a choice? This choice must be clear and remain stable over time. If the patient cannot (or will not) communicate a choice, the interviewer cannot assume that the patient has the ability to make a decision. (Consider one extreme: Someone who is in a coma.) If the patient repeatedly changes his choice, this has practical implications: A medical team and patient agree to launch Plan A. Right when Plan A is about to unfold, the patient refuses it. The team cancels Plan A, but then the patient says he wants Plan A. This is a problem.

The case patient appears to be communicating a consistent choice (refusing intubation).

2. Does the patient have an understanding of relevant information? Does the patient understand what the diagnosis means? the risks and benefits of proposed treatment? the risks of benefits of alternative treatments (which includes doing nothing)? Again, consider an extreme: If a patient does not understand that surgery involves the cutting of skin, that patient cannot make informed decisions related to surgery.

The case patient was able to comment that “refusing intubation would lead to his death.” He was apparently “unable to, or chose not to, articulate any reason that he did not want to be intubated”. From the available information, we do not know if this patient understood that he had a lung injury. (Was his choice based solely on the unpleasant thought of someone shoving a tube down his throat?) We also do not know if he understood the risks and benefits of intubation and mechanical ventilation.

3. Does the patient have an appreciation for the current circumstances and consequences? This may sound similar to #2, but there is a notable difference: This question asks if the patient understands the condition and treatment options as it applies to him. Patients with dementia, for example, might know the course and outcome of dementia after witnessing the condition in a relative, but may not recognize that their own cognitive function is impaired. Similarly, consider a procedure that results in death 50% of the time. If a patient says, “I’m not like everyone else! There’s absolutely no chance I will die!”, he lacks the ability to make informed decisions for himself for this specific issue.

It appears that the case patient recognized that if he refused intubation, he would die. We do not know if he understood that he himself had a lung injury and how available treatment might help (or hurt) him. (As an aside, one could argue that the patient has already demonstrated ambivalence about death and dying. Most people who have made the commitment to die generally will not go to an emergency room “on three consecutive days for suicidal ideation and non-life-threatening suicidal gestures”.)

4. Can the patient manipulate information in a rational manner? This asks if someone can apply sufficient logic to his current situation. Another extreme: If someone has the unshakable conviction that all surgeons implant microscopic, parasitic aliens into patients during operations, that patient lacks the ability to make informed decisions related to surgery.

From the available information, it is unclear if the case patient could manipulate information in a rational manner for this specific situation. We do not know the reasons why he did not want to be intubated. One reason could have been his stated desire to die. We do not know if he believed that he would have access to endless opiates in the afterlife. We do not know if he felt overwhelming guilt for damaging a tree and thus believed that he deserved to die. It may be unfair to assume that he cannot manipulate information in a rational manner simply because he could not state reasons for refusing intubation. However, it is also unfair to assume that he can manipulate information in a rational manner in the absence of data.

You may now recognize the amount of time and information needed to render an opinion about decisional capacity. (Furthermore, I personally believe that anyone rendering these opinions should consult with colleagues for quality control. Our personal biases affect our judgments. These extra discussions consume more time.) As a result, this process often cannot occur in acute medical situations.

Given the limited information (due primarily to the acuity of the situation), it is not clear if the patient had the decisional capacity to refuse intubation and mechanical ventilation for treatment of his lung injuries. One might lean more towards the opinion that he lacked decisional capacity, since he did not provide a convincing argument that he understood the relevant information or appreciated the situation and the consequences.

In addition to the rubric described above, some authors argue for a “sliding scale” in decisional capacity. If the patient in Shadowfax’s case was intubated, the physicians likely applied this “sliding scale”. I will describe it in further detail in a later post. For a preview, look over the comments in Shadowfax’s post.


Unsolicited Advice to Residency Applicants.

A medical student recently told me that he wants to become a psychiatrist.

“What should I look for in residencies?” he asked.

I wrote the following in September 2007. Though I am now a few years out of training, I believe much of the information still holds true. If you will be applying for a residency slot later on this year (regardless of specialty), you may find the suggestions below useful.

So, you are in your final year of medical school and will soon begin life in post-graduate training (because overeducation will help you lose weight! have more confidence! get you a lot of dates!). You’ve selected a specialty. What are some things to look for while you attend your interviews in your black suit while clutching your black, leather-bound folder? What are questions to ask of the people you meet? What are some things you ought to consider that may significantly impact your training experience?

How many clinical sites are in the program? The more clinical sites generally means more exposure to clinical diversity. If you train only in a community hospital, you’ll learn to manage common medical events, but you’ll miss out on more exotic cases. If you only train in a private sector hospital, you’ll become familiar with the medical problems of people who have money and/or insurance, but miss out on the indigent population and people who can’t afford healthcare (which includes a lot of people). The number of clinical sites will affect your clinical experience and “fund of knowledge”.

However, the practical aspects of clinical work become complicated with each additional clinical site. If you are in a specialty that includes an outpatient component, your clinic may be at Orange Medical Center, but you may be on an inpatient rotation at Apple Hospital. Getting from Apples to Oranges could be frustrating, particularly if you cannot chart for Apples while at Oranges. Keep in mind the practical aspects of travelling from one site to another: Is there a shuttle system? How reliable (and efficient) is public transportation? If you drive, how is traffic between Site One and Site Two? What about parking?

Furthermore, the more hospitals involved in the residency program could potentially mean more call. Although the number of residents in any given program is directly proportional to the number of medical centers in a residency, that doesn’t mean that there are necessarily enough residents to permit a decreasing call burden as one advances in the residency. (For example, there are many psychiatry residents in the country who do not take any call as third- and fourth-year residents. This sounds almost obscene to those of us who do did.)

What do the current residents have to say about the residency program director? If the residents generally malign the program director, then this does not bode well for the residency. Find out the reasons for the disdain: Does the program director ignore resident comments and complaints? Is the program director more concerned about his/her status in the academic hierarchy rather than resident welfare? Has the program director repeatedly refused to advocate for residents?

If the residents say little about the program director (“who?”), this is also worrisome: Does this mean that the program director is never around? Does s/he (purposely?) limit contact with residents? How do residents deal with residency-wide problems?

Obviously, not everyone is going to like everyone else (including the program director), but you want to look for a program where people respect the residency director.

How involved is the department chair in resident education? This is difficult to suss out and doesn’t seem entirely relevant, but the department chairperson does indirectly affect the resident experience. If the department chair doesn’t care about resident education, that means that the chair will not support the residency director. (See the previous point.) If there are attendings who are atrocious towards residents, but are nonetheless producing excellent research or are otherwise bringing in The Big Bucks, these attendings will continue to participate (or not, if that’s the problem) in training residents.

If the chairperson meets applicants during residency interviews (whether formally or not), this is encouraging. If the chairperson interviews applicants, this is also encouraging.

Do the residents like each other? This is obvious. You don’t want to work with people who can’t tolerate each other.

Does the residency try to make your life easier? Much of this may actually depend on the School of Medicine, as that is where each residency obtains much of its funding. This is what I mean by “make your life easier”:

  • Do you have to pay for your own meals while on call? Does the residency reimburse you for meals? Do residents have a “meal card” that they can use with ease while on call to get food?
  • Do you have to pay for parking? (This adds up.) How far are the resident parking lots from the hospital and clinics? Does the residency offer a voucher for public transportation (bus pass, etc.) so you can travel at a discount or, even better, for free?
  • Does the residency provide (cheap) options for health insurance? dental insurance? life insurance?
  • Are residents permitted to participate in a savings program? Will the institution match the donations you invest?
  • What provisions are in place to maximize your safety? Will security officers walk you to your car at your request if you’re leaving the hospital at a late hour? Can you get a ride to a safe bus stop?
  • If an electronic medical record is in use, does the IT department want your feedback? Can you chart from your computer at home? If not, why not? If so, do you need extra software, security clearance, etc.?
  • Do residents have an “education fund”, where the residency provides money for the residents to purchase books or attend conferences? How much is in that fund? Does it roll over with each year?

What is the balance between service and education? Ask the residents how the residency provides education. (The incorrect answer is: “Oh, we kinda run the hospital.”) Is there dedicated time for residents to attend didactics? Do these formal teaching sessions occur on a weekly basis? monthly basis? as needed harangued basis? Who teaches the residents? Are the attendings in clinical settings invested in resident education, or merely invested in scutting out residents? Are there case conferences? journal clubs? Who organizes them? Who attends them? (It doesn’t count if the residency “offers” them, but the residents feel too saddled with work to actually participate in them.)

Do you want to moonlight? Most people don’t go into residency with this question in mind and perhaps I am not in the best position to address this: I do did not moonlight, as I much prefer having time over money. However, if you have plans to start a family, want to pay off your loans as soon as humanly possible, desire to purchase property, or otherwise want to bring in the BLING BLING to charm the ladies (…), inquire into moonlighting opportunities and difficulties. Some residencies (or, more commonly, the associated Schools of Medicine) won’t let you moonlight within the clinical institutions in which you work (e.g. the ER). Some residencies won’t let people moonlight within a certain geographical distance. Driving fifty miles to work on a weekend sucks. (Refer back to the first point about clinical sites: These other psychiatry residents who do not take call as senior residents are often moonlighting within the clinical institutions and thus are (1) providing call coverage anyway and (2) making BANK while doing so.)

What do you like to do when you’re not working? Do not be mistaken: As an intern, you won’t be doing much other than working, sleeping, and performing necessary ADLs (Activities of Daily Living—bathing, eating, etc.). However, as you progress in your training, you should have more time away from work. If you love to fish, attending a residency in a land-locked area is not a good idea. If museums and viewing plays are sources of joy in your life, a rural residency probably won’t sustain you.

Of course, you can cultivate new hobbies wherever the Match sends you. The opportunity to immediately continue your interests upon relocation, however, allows you to build your (non-medical) social network rapidly. And you may find that your non-medical friends, in engaging you in your non-medical hobbies, offer invaluable support when the fangs of medicine have latched onto your soul and are draining you of your Life Force.

Now that it’s four years later, I would add two more things:

Where do the graduates of the residency go and what are they doing? Everyone has their own interests, of course, but this information can at least suggest how the residency has trained people for “real life”. If graduates end up throughout the country in a variety of positions, this could mean that the residency provided excellent training that prepared graduates for different jobs. (It could also mean that graduates disliked living in the city where they trained and wanted to get out as soon as possible.) If graduates all end up working in the clinics and hospitals associated with the residency, this could mean that graduates couldn’t get jobs anywhere else. (It could also mean that they didn’t want to work anywhere else, which could reflect well on the academic center.) If graduates end up not practicing medicine… well, you get the idea.

Is there stability within the administration? Things change all the time, though significant change within higher levels of administration (chairs, vice chairs, chiefs of service, etc.) can make the lives of residents more stressful. When leadership changes, that can lead to changes in policies and practices that can directly affect training experiences. The balance between service and education could shift. The number of training sites could increase or decrease. Call schedules could change. Faculty turnover might suddenly increase. These changes may be long overdue and everyone might welcome them with open arms, but change—even for the better—can still lead people to feel anxious or uncomfortable. Leadership instability isn’t reason alone to avoid a residency, though you might want to ask more questions to learn more about the reasons behind the changes.

Best wishes to the medical students who will be applying for residency slots. May you be offered way more interviews that you can attend and courted with enthusiasm and vigor. The Match will come sooner than you think.


Termination (II).

During psychiatry training, residents are assigned “psychotherapy supervisors”. The resident sees a psychotherapy patient and then meets with his supervisor to review the session. Sometimes this means the resident will dump onto paper everything he can remember about the session: “She said A, that made me think about B, so I said C, and then she replied with D”. Sometimes, with the patient’s permission, the resident records the session on audio- or videotape. Together, supervisor and resident later review this data. The supervisor provides feedback and suggestions to teach the resident about psychotherapy and how to proceed with treatment.

During my last year of residency, one of my supervisors was a psychoanalyst. Every week, I went to her private office for supervision. A plush psychotherapy couch was near the window. She sat in the chair behind the head of the couch. I sat in the chair across from her.

About four months prior to my graduation, my patient—a man who had been single for several years—started dating a woman who worked in health care. I thought this was a positive development: Maybe he had learned that others did not share the opinion he had of himself. Maybe he learned to view himself with more compassion. Maybe he had developed more confidence when interacting with women.

When I shared this information with my supervisor, she looked at me with disbelief. She insisted that this was his reaction to termination.

“It’s a flight into health,” she said. “He’s found this woman now because you’re leaving.”

What is a “flight into health”? Malan says:

[It is] a concept which at first sight may seem to contain an inherent paradox. The paradox can be resolved by making it clear that the flight is into apparent health—the patient believes he has recovered but the clinician believes that unsolved underlying conflicts will give rise to more or less serious difficulty in the future…. [A flight into health may be] a way of avoiding either further painful conflicts or anxiety-laden feelings about [the] therapist. (p. 219)

“She works in health care, you work in health care. You are an important person in his life; he wants this new person to be an important person in his life. Don’t you think it’s interesting that he found this relationship right when you are about to leave?”

It was my turn to look at her with disbelief.

“How do you know this is all about me? How can you be so sure?”

My supervisor and I often revisited this topic in the remainder of our meetings. In fact, she wondered if my opposition to her suggestion was significant in our termination, the end of our educational relationship. (And, as psychiatrists are trained to do, we talked about it. Neither one of us changed our opinions.)

Though I disagreed with her assertion about my patient, I was more vexed with her unshakable confidence in her hypothesis. How could she know that she was absolutely correct?

Malan summarizes my sentiments about this issue:

… the therapist sees all the problems that his brief therapy has not resolved, and—in ignorance of systematic follow-up evidence—has no faith in the patient’s ability to mature further. (p. 218, emphasis mine)

Frick also argues that the concept of “flight into health” is cynical.

Neither my supervisor nor I pursued follow-up with this man. Only time would tell if his relationship signified recovery or avoidance.

To be clear, “flights into health” can happen. Some people find it much easier to believe that their conditions have improved, rather than acknowledge and endure “the pain and anxiety of further exploration and self-disclosure” (Frick).

Whether related to termination or not, what we say or think about someone often reveals more about us than about the person in question.

Education Nonfiction

Termination (I).

In mental health, termination is the word used to describe the process of ending psychotherapy. Note the word “process”: Termination should not be an anvil falling from the sky. Under ideal circumstances, patient and therapist address termination during their initial meeting.

Think of termination as an exit interview for psychotherapy that spans several appointments. Patient and therapist review what the patient learned about herself, her accomplishments and goals (did she reach them? did they change during the course of therapy? if so, why? etc.), her reactions to and opinions about treatment, and how she might use the experiences in therapy to help her in the future.

In this way, termination facilitates closure, that “often comforting or satisfying sense of finality”.

Termination can be a Big Deal because, for many people, the end of meaningful relationships is difficult. People can experience emotions that are not only distressing, but also compel them to behave in ways that are neither helpful nor effective. Think about a relationship you had that you believe ended poorly: The girlfriend or boyfriend who dumped you. The unexpected death of a parent or sibling whom you both loved and disliked. The dear friend who drifted away, purposely or not.

Sometimes, even for those uncomplicated relationships that end “well”, we feel conflicting emotions about them. Loss is difficult for most, if not all, people. It’s hard to say good-bye.

Thus, ideally, termination is neither abrupt nor unexpected. Both patient and therapist may recognize that the patient has achieved the goals of therapy (determined at the outset of treatment and adjusted accordingly, right?). In this instance, termination makes sense. Nevertheless, patient and therapist may still feel powerful emotions while going through this exit interview.

In reality, termination can be both abrupt and unexpected. Patients move; therapists move; the Stuff of life interferes with and prematurely ends the therapeutic relationship. If the patient feels connected to the therapist, the patient may then activate old habits of dealing with loss and strong emotions. These habits may have been the very things that brought the patient into treatment. Many therapists therefore believe that termination is the most important aspect of psychotherapy.

In the next few posts, I will write more about the reactions people—patients and therapists—may have during termination.