Month: November 2015

Categories
Consult-Liaison Education Informal-curriculum Lessons Medicine Reflection

What is the Question?

I can think of only two times in my life where I received formal instruction on how to ask questions.[1. Without a doubt there have been more than two occasions when someone taught me how to ask questions, but it appears that I either was not paying attention or the lesson was not memorable.]

The first instance was when my parents taught me how to order food in a restaurant. They told me to make a single choice and have my order ready before the wait staff appeared. (“Don’t waste their time.”) They told me to phrase my order in the form of a question:

RIGHT: “Can I have the grilled cheese sandwich, please?”

WRONG: “I want the grilled cheese sandwich.”

My parents also told me to look at the faces of the wait staff and to speak loud enough so they could hear me. They also told me to thank them after they took my order.

(When I became more finicky about sentence construction, I changed the beginning of my orders to “May I…?”. This is mostly due to my 6th grade English teacher who, in his booming voice, would challenge any student who said, “Can I…?” “I don’t know, CAN you? CAN you go to the bathroom? If you CANNOT, perhaps you should see a DOCTOR. MAY you go to the bathroom? Yes, you MAY.”)

In sum, I was supposed to know what I wanted and exercise good manners.

The second time I received formal instruction on how to ask questions was during my third year of medical school.[2. Of course I received formal instruction on how to ask questions throughout my training as a medical student and as a psychiatry resident. However, that was over the course of years and done with varying quality. There were also all the people who taught me how to ask questions and I didn’t understand at the time that they were teaching me how to do that. Communication is difficult. This also explains why my efforts to ask boys out on dates in my youth often resulted in said boys looking at me askance and running away.] Interns and residents often asked medical students (e.g., me) to call consults.

Here’s the thing: When you’re a medical student, you don’t know how to do things like call consults because you don’t entirely know what you’re doing. Mastery comes with practice. Mastery also results from direct feedback, which often comes from exasperated and impatient residents.

When you call a consult you’re asking another service to help you with your patient. For example, if I’m a surgeon and I have a patient who stabbed himself multiple times in the abdomen in an attempt to kill himself, I’ll do the surgery to look around inside and make sure there aren’t injuries to internal organs. However, as a surgeon, I don’t know what to do about my patient’s urges to stab himself, so I’m going to call the psychiatrist to ask her for help.

WHAT IS THE QUESTION?

A surgical intern named Tom[3. Tom had cropped blonde hair. He wore leather pants sometimes. He often went dancing when he wasn’t working. He was smart and, perhaps more importantly, he was kind.] taught me how to call a consult while we were speeding around the hospital one day.

“Before you call a consult, you have to know what you want. What is the question you want answered? The patient is your patient, so you have to provide most of the care. But if you need help, what do you need help with? Don’t just say that the patient has diabetes and high blood pressure. That’s not a question and it’s not clear what you want. Make your question very clear:

‘My patient has diabetes and high blood pressure. He took insulin regularly before he came to the hospital, but now his blood sugars are high. They haven’t been below 300 since he’s been here. Can you help us bring his blood sugars back down?’

See how that’s a clear question? If you ask a clear question, you’ll get answers that will actually help you.

And be nice. Some of the residents you talk to won’t be nice, but that’s just because they’re tired and stressed out. Don’t take it personally.”

In sum, I was supposed to know what I wanted and exercise good manners.

To be clear, it’s not like I had this one conversation with Tom and I thereafter called in stellar consults. I still went on for too long and didn’t share pertinent pieces of information. Residents interrupted me before I had spoken for five seconds and they often made no effort to mask their annoyance.

But! It set me on the path of continually clarifying for myself what I wanted and how to craft better questions. Focusing on “WHAT IS THE QUESTION” has helped me as a psychiatrist (much of the work is often helping other people clarify for themselves what they want), a teacher (if people don’t understand something and get stuck, it’s often because they don’t know what they want to know), and as a human being (when meeting someone new, the question might be as simple as, “How can I make this person feel comfortable so maybe we can become friends?”).

Sometimes asking questions is more complicated than just knowing what you want and exercising good manners (e.g., “Will you marry me?”). Doing both, though, is an excellent place to start.

Categories
Nonfiction Reflection

Thanksgiving.

As my father and I came out of the clearing and saw the shore, he exclaimed, “Wow—it’s so pretty!”

shore

We started walking more slowly. The air was cold on our faces, but the sun warmed our backs. He squinted at the shining water and I saw his exhalation transform into grey wisps.

“Sometimes things are so good that it feels sad,” he murmured.

When I met a friend for lunch yesterday, I confessed, “Something about today is making me miss my mom. I don’t know what it is. It’s not the weather, because it never got this cold in California.”

“Maybe it’s because it’s sunny,” he guessed.

He had a point: It is usually not cloudless and sunny at this time of year in Seattle. When I stepped outside my face reflexively scrunched up; the sun was so bright! But I knew that wasn’t it, either: The sunlight in Seattle looks more “sharp” and white; the sunlight in Southern California looks more “soft” and yellow. (I assume that there is science behind this perception, whether it is actually a function of latitude or a function of my retinas.)

Later in the day I realized that we were close to the Thanksgiving holiday. Today I realized that yesterday was November 21st.

My husband and I were seated at a corner table in a restaurant in Sea-Tac airport on November 21st, 2013. I had ordered a plate of nachos. Our flight to California to see my parents was scheduled to take off in about 90 minutes.

My phone rang. It was my father. My father never called me. Something was wrong. I stepped out of the restaurant.

“Okay, Maria,” he said. He was trying not to talk fast. “Mom went to the hospital today.”

“What?” I blurted. “What happened?” Accident? Injury?

My father had worked as a computer programmer. He was trying to remember all the words the doctors had used.

“She’s on the second floor of the hospital, in a room by herself, a special care unit—”

“Intensive care unit?”

“Yes, yes, intensive care unit. They took her directly there. They said that she would be monitored overnight because she has water and blood in her lung.”

“Water and blood in her lung? Blood clot?”

“Yes, blood clot. I think in her right lung.”

Pulmonary embolism? From what?

I tried to not talk too fast, either: “Did they say how big the clot is?”

“Medium-sized? It was really hard for her to breathe.”

“And water around her lungs?”

“Yes, they said it was a lot of water. They also did some scans, see-tee? CT scans. They said that there is something in her lung. Both lungs?”

Cancer.

“Did they tell you what they think it is?”

“No, not yet. They said that the doctors will know more tomorrow.”

He then asked me if I could reschedule our plans to visit Disneyland the next day. I almost laughed out loud at the absurdity of his question.

I don’t know if I believe the idea that our bodies remember things that our minds don’t. I don’t disbelieve it, but I can’t explain it.

It’s hard to talk about things you can’t explain.

There are and will be plenty of blog posts exhorting us all to express gratitude this Thanksgiving holiday. I won’t run through a list of things you and I “should” be grateful for. To be clear: I do encourage you to go through the exercise (and not just on Thanksgiving), but these reflections are often best done in solitude.

As you we think about all the things we are thankful for, it’s not uncommon for us to feel a swirl of different emotions. That’s okay: We feel the way that we feel. Sometimes things are so good that it feels sad.

Categories
Consult-Liaison Education Funding Medicine Policy Systems

The Value of Psychiatrists.

While slogging through a crappy first draft of a document about the value of psychiatrists in mental health and substance use disorder services, I did a literature search for supporting evidence.

I found nothing.[1. Physicians, as a population, don’t advocate for ourselves as much as we should because we’re “too busy taking care of patients”. This is true. However, our busy-ness creates a vacuum where non-physicians step in and make decisions for us. We then express resentment that we have to follow the edicts of people who have never done the work. If we did a better job of regulating and advocating for ourselves, we might not be in this position.]

“So how exactly are we helpful?” I mused out loud. Maybe we aren’t: There are groups out there who do not believe that psychiatrists can or do help anyone.

I am an N of 1. Therefore, this post is an anecdote, not evidence. Nonetheless:

Psychiatrists provide psychiatric services. These are increasingly limited to only medication management, which is unfortunate. Psychiatrists need psychotherapy skills—or, abilities to connect with people to build trusting and respectful relationships—to do effective medication management. I can write dozens of prescriptions and change doses as much as I want, but if the person I am working with doesn’t trust me, none of my tinkering matters.

When people think about medication management, they often think only of adding medications or exchanging one for another. Medication management also includes helping people come off of medications. This “deprescribing” also requires the use of psychotherapy skills: Some people feel great discomfort when coming off of medications. Sometimes the reasons are physiological; sometimes they’re psychological. Psychotherapeutic interventions and education are necessary in helping people cope with and overcome these discomforts.[2. For any psychiatrists out there: You could build an entire practice around “deprescribing”. This is one of the most common clinical requests I receive through my blog. I don’t have a private practice, so I turn all these people away. To be clear, deprescribing isn’t limited to private practices; I deprescribe in my clinical work in the jail.]

Psychiatrists often have the most clinical expertise. Most have had exposure to the spectrum of psychiatric services (in residency training) and thus have perspective about how systems work (or fail). Thus, psychiatrists can provide clinical consultation about specific patients and program design, implementation, and improvement. One example is the use of medication assisted treatment for substance use disorders. Certain programs or agencies may believe in abstinence only and will view medications as another misused substance. That perspective is not invalid, though giving people more options may help someone reach the goal of abstinence.

Psychiatrists can provide education to other staff to improve their clinical skills, which can elevate the quality of care clients receive across the agency. Psychiatrists can also provide leadership and influence the direction and ethos of a clinical service. For example, you can imagine how a psychiatrist might influence a service if he believes that the only way to help patients is to convince them to take psychotropic medications forever. A different psychiatrist who believes that employment or housing may be more effective than medication for some patients would provide a different influence.

Psychiatrists can triage patients who are in crisis. A roving psychiatrist on the streets or visiting people in their homes often can’t do things like draw blood, but they can assess people and circumstances to determine whether a visit to the emergency department can be avoided. Psychiatrists can also provide strong advocacy: Psychiatrists can work with law enforcement so that people who would be better served in a hospital actually go to the hospital, and not to jail. Similarly, if someone who has a significant psychiatric condition requires medical attention, psychiatrists can talk with hospital staff to advocate for this. Too many of us have stories about our patients who needed medical interventions, but others thought their symptoms were entirely due to psychiatric conditions.

Psychiatrists go through medical training and often have ongoing contact with other medical specialties. They are thus familiar with the practical realities of communication about and coordination of care for patients across systems. While overcoming the financial and policy hurdles to integrate care are important, the reason why integration matters (or, at least why I hope it matters) is to improve the experience for the patient. Administrators should consider the interaction and experience between the physician and the patient as paramount. The system should not sacrifice that relationship to make administration easier.

This is the message that all physicians, psychiatrists or otherwise, need to communicate to administrators. We don’t do ourselves any favors by assuming that people know what value we bring to patients or to the system. Sometimes it also helps to remind ourselves, too, so we can improve our work for the people we serve.

Categories
Consult-Liaison Education Medicine

Foundations.

I never did follow up here on the talk I gave to attorneys about “Psychiatry 101“. Teaching the foundations of any subject is both challenging and rewarding. It is also an excellent way to remind ourselves of the importance of the basics. Foundations anchor and guide us, particularly when we start getting lost in complex or unusual situations.

During my talk I review the definition of “mental disorder”.[1. I dislike the term “mental disorder”, primarily because of the stigma attached to it. The term focuses on what is wrong, not what is going well. We also get so caught up talking about “disorders” that we stop talking about “people”.] DSM-5 states that a mental disorder has two components:

  1. disturbance in cognition, emotion regulation, and/or behavior (the assumption is that pathology in the brain/mind manifests as this disturbance)[2. The underlying assumption that “disturbances” reflect pathology in the brain/mind is up for discussion, given that we don’t know if there is a distinction between the brain and the mind. The two seem related, but how they are related remains unclear. Furthermore, some people would argue that not all disturbances represent pathology. Context matters. People who choose not to eat during a hunger strike against the government are demonstrating a “disturbance” in behavior. Does that represent pathology?] AND
  2. the disturbance leads to distress OR impairment/disability

Both conditions must be met. However, the second criterion has two parts. This complicates the definition of a mental disorder. Distress does not equate to disability. People can experience low distress and high disability: Consider the person who has lost all his relationships and is unable to hold a job because he believes that he is the Messiah. People can also have high distress and low disability: Take someone grieving the loss of his spouse.

Symptoms help define diagnosis, and diagnosis guides treatment. Danger arises when psychiatrists treat symptoms without a clear diagnosis. An analogy: Say you are lost in a city. You call your friend to pick you up.

“Where are you?” your friend asks.

“I don’t know,” you respond.

“What street are you on?”

“Main Street.”

“Main Street and what?”

“Um… Main Street and Popcorn Alley.”

“Okay. Stay there are I’ll be there in about 15 minutes,” your friend says to your relief. You and your friend were able to define where you were located, which allowed your friend to figure out how to get from his house to Main Street and Popcorn Alley.

But what is the conversation went like this?

“Where are you?” your friend asks.

“I don’t know,” you respond.

“What street are you on?”

“I don’t know. The streets don’t have signs on them.”

“Okay. What do you see around you?”

“Uh… there’s a coffee shop on one corner and a sandwich shop on the other corner.”

“What else do you see?”

“Well, there’s a parking lot across the street.”

At best your friend would probably express gentle frustration with your lack of clarity: There are many coffee shops, sandwich shops, and parking lots in the city. How is he supposed to find you with such vague directions? At worst your friend would say, “Okay, I’ll find you,” and then hop into his car and drive around, looking for the triad of coffee shop, sandwich shop, and parking lot. The diagnosis (location) is unclear, so the treatment (picking you up) is also unclear (and frustrating and wasteful).

There is variability in how psychiatrists approach diagnosis of a “mental disorder”. The criterion of “disturbance in cognition, emotion regulation, and/or behavior” is often the easier of the two to determine: Most people would agree that people who cut themselves, refuse to eat, or feel so hopeless that they literally can’t get out of bed are experiencing a “disturbance”.

If the disturbance leads only to distress, but not disability, does that mean a mental disorder is present?

Here are several instances of disturbance AND distress WITHOUT disability:

  • hearing voices say unusual things to you
  • having self-doubts and feeling terrible following a breakup
  • suspecting others of sabotaging your work

If these things happen to you, does this mean you have a mental disorder? Maybe, but not necessarily.

Here are several instances of disturbance AND impairment WITHOUT distress:

  • hearing voices say that you are God and that you should touch everyone to bless them
  • having beliefs that you do not need to eat or drink to live; air alone will sustain you
  • suspecting others of sabotaging your work, so you stop going into the office, never talk to anyone, and don’t share any of your data (some distress is probably associated with this)

If these things happen to you, does this mean you have a mental disorder? The impairment component makes it more compelling that a disorder is present. (Why, yes, I know my bias is showing.)

If we do not exercise diligence in our diagnosis of a “mental disorder”, then we may suggest an intervention that is incorrect or insufficient. Even worse, the treatment may be unhelpful or harmful.

We work with our patients to discern whether a mental disorder is, in fact, present. Together we then clarify what the mental disorder is. Lastly, we survey possible interventions.

This is the value of returning to foundations.

Categories
Reading

Interesting Internet Items Over the Past Week.

I try to read more books instead of stuff on the internet.[1. The only way I successfully motivate myself to read more books is to keep a log of what I’ve read. I’m doing better this year than I did last year, but I still wish the list were longer. These are the books I’ve read this year thus far, where recommendations are in bold:
Influence (Cialdini)
Obvious Adams (Updegraff)
Your Illustrated Guide to Becoming One with the Universe (Sakugawa)
Essentialism (McKeown)
King Solomon’s Ring (Lorenz)
When Things Fall Apart (Chodron)
Seven Habits of Highly Effective People (Covey)
The Wisdom of No Escape (Chodron)
Shelter for the Spirit (Moran)
Gone Girl (Flynn)
Toyota Kata (Rother), but did not finish
No Exit (Sartre)
The Ten Golden Rules of Leadership (Soupios)
The Lessons of History (Durant)
Pebbles of Perception (Endersen)
The Stranger Beside Me (Rule)
Yoga Wisdom at Work (Showkeir)
and One Day in the Life of Ivan Denisovitch as listed above.] I recently finished (and recommend with enthusiasm) One Day in the Life of Ivan Denisovitch, which is both depressing and amusing. I put it in the same category as Frankl’s Man’s Search for Meaning, a book I consider essential reading for everyone.

Here are some interesting items from the internet, rather than books, I read over the past week:

The Ghosts in Our Machines

When’s the last time you’ve spotted someone you know on Google Maps? I never had. And my mother, besides, is no longer alive. It couldn’t be her.

Strong Placebo Response Thwarts Painkiller Trials

But the finding that placebo responses are rising only in the United States is the most surprising aspect of the latest analysis.

How Government Killed the Medical Profession

Once free to be creative and innovative in their own practices, doctors are becoming more like assembly-line workers, constrained by rules and regulations aimed to systemize their craft.

The Violence of Algorithms

Much of the data used was inputted and tagged by humans, meaning that it was chock full of human bias and errors. The algorithms on which the system is built are themselves coded by humans, so they too are subjective. Perhaps most consequentially, however, although the program being demonstrated was intended to inform human decision-making, that need not be the case.