Nonfiction Observations Reflection

(Stupid) Status Games.

I only noticed later that he had a taser on his belt, which means that he was probably a sergeant.

After the doors closed and the elevator lurched into motion, he turned to me and said, “C’mon, smile! It’s not so bad.”

His comment snapped me out of my reverie. I turned my head to look at him and reflexively smiled, though immediately wondered why. His glasses lacked rims and his head lacked hair.

“Are you almost done with your day?” I asked. Maybe he was having a bad day.

He snorted before he glanced at his watch. “Eh… maybe.”

Shift change was in less than 45 minutes.

“Might you have to work mandatory overtime?” The officers I work with often learn of their mandatory overtime shifts about an hour before the next shift begins.

“Ha! No,” the officer laughed. He looked at me again as the elevator reached my floor. “I’ve worked here longer than you’ve been alive.”

Now, in retrospect, I should have let that one go. Maybe he was giving me a compliment: You look young! The sneer in his voice, though, suggested that he wasn’t.

“I think you believe I’m younger than I actually am,” I said over my shoulder as I walked out of the elevator.

“I’ve been working here for 36 years!” he called after me.

“I’m older than that,” I said, without turning my head.

Before the elevator doors slid completely shut, he shouted, “NOT BY MUCH!”

“I’m pretty sure he wouldn’t have said, ‘I’ve worked here longer than you’ve been alive,” if I were a guy,” I complained to my female colleagues.

“Yeah… but, you know, he was right: You’re not much older than 36 years.”

Observations Reflection Systems


No one was sitting near us at the fast food chain, but my dad lowered his voice anyway.

“You were three or four years old,” he said. “We were watching an NBA game on TV. You asked, ‘Where are the white people who play?’ Even little kids notice these things.”

“How did you answer my question?”

“I didn’t.”

About 5% of inmates in the jail are in psychiatric housing at any given time. My current post assignment is with males who demonstrate acute symptoms, which comprises about 2% of the entire jail population. A small team works with this 2%.

To be clear, not all people with psychiatric conditions are put in psychiatric housing. Sometimes people start there and, as their condition improves, they move on to general population housing. Some people with psychiatric conditions never come to psychiatric housing. How one behaves, not one’s diagnosis, determines where one is housed.

I don’t know if the racial mix of my patients is proportional to the racial mix of all the people in jail. It’s rare that the patients I care for are comprised of only one race. I have yet to ask, “Where are all the white people?” However, I’ve certainly asked that before in another correctional setting.

I’ve often framed the processes of clinical work as a game. Maybe this is a product of clinical training: When working in hospital services, you’ve “won the game” if you were able to discharge all of your patients. You make informal wagers as to the duration of rounding: “Oh, our attending is Dr. So-and-So, so we’ll finish in less than an hour, tops,” or “Dr. Blah-Blah is on service now. You think three hours? Four? Five?!”

It’s probably just one way of coping.

While on various outreach teams, the objective of the game was to keep all of my patients out of the hospital. When working in a clinic in a medical center, it was to get all my patients well enough so that I could send them back to primary care. Now, the game is to get them out of the most acute unit and prevent them from returning. (The object of the game really should be how to keep people out of jail. That requires coordinated efforts across space and time, particularly for people with complex psychiatric conditions.)

Sometimes my patients are young black males. Sometimes they talk about problems they’ve had with officers or other inmates in the jail.

“I don’t want you to come right back to this unit if we send you out.” That’s how I usually start it. “If someone else gives you a hard time or starts being a jerk to you, what are you going to do to help you stay there and not get sent back here?”

People are often doing much better by the time we’re able to have this conversation. They usually provide reasonable answers.

Even though no one else is sitting near us, I then lower my voice.

“You’re a young black man. Some people here—not everyone, but some of them—react to you in certain ways just because of the color of your skin. That’s not fair, but, sometimes, that’s what happens. You know this much better than I do.”

I remain struck with how their faces soften. Jail is a hard place to be and people adopt hard expressions on their faces. When this coversation happens, these young black men invariably smile, but not from joy.

“So if something happens, you have to figure out how to respond so that you’re not the one who comes back here. Does that make sense?”

Sometimes they thank me for talking about race; sometimes they tell me that they already know what they need to do; sometimes they simply assert, “Don’t worry, I won’t come back here.”

Why do I lower my voice when I talk about this? Would I bring this up if I were a white female? a white male? Does the fact that I look obviously Asian work in my favor? Do I need to bring up something that they already know? Am I just being rude? Do good intentions matter when people find the intentions condescending?

Am I actually helping them when I frame things this way? Or am I only making myself feel better?

It’s a small sample size and completely anecdotal: After we have this conversation, they don’t return to the unit.

Maybe they were never going to come back, anyway.

Lessons Nonfiction Observations Reflection

On Knowing Yourself.

I know of only two people who, upon starting medical school, knew that they wanted to become psychiatrists. (How did they know what they wanted to do eight years before they did it???) They both achieved their professional goals: One created a community clinic for people with severe psychiatric illnesses. The other became an addiction psychiatrist and now oversees an entire substance use disorder program for a health care organization.

I was not one of those people. As a youth, I aimed for family medicine, a generalist that would help people of all ages. While studying microbiology in college, I aimed for infectious diseases: The ingenuity of single-cell organisms! The science behind antibiotics and antiretroviral medications! The elegance of diagnosis and treatment! (My fascination with microbiology persists.) In medical school, I learned that infectious disease is a subspecialty of internal medicine and, WOW, there are a lot of subspecialities within internal medicine! Oncology (cancer) and nephrology (kidneys) captured my attention for a while—more incredible physiology that occurs on a cellular level!—and, then, seemingly out of nowhere, appeared psychiatry.

We’re biased when we look back at how things unfolded: We can’t change the past, so we tell ourselves that it all worked out the way it was supposed to. So, yes, of course I was supposed to go into psychiatry all along.

It became clear during my psychiatric training that I prefer to work with people who are experiencing severe psychiatric symptoms, particularly psychosis (e.g., people who hear voices saying terrible things about them, people who believe that someone has exchanged their internal organs for someone else’s). I also like the intersection and interplay of physical and mental conditions: Sometimes people who have significant medical illness develop striking psychiatric symptoms, which resolve along with their medical illnesses. Sometimes people with significant psychiatric illnesses develop significant medical problems, and successful treatment of both conditions requires teamwork. Complex problems are fascinating. Witnessing people recover from complicated conditions is rewarding. I’m lucky that I have had the opportunities to do this work.

I’ve also recognized that I am not consistently warm and empathic to people who are experiencing mild psychiatric symptoms. Two previous patients come to mind:

  • “I’m so stressed out,” she said while wringing her hands. She began to pick at the tassel of her Coach bag. “I don’t know which to remodel first: The beach house? the pied-a-terre? or the kitchen in our home? It’s all I think about and I’m starting to lose sleep over this.”
  • “My girlfriend started taking Prozac a few months ago, and it seemed to really help her. She has a lot more creativity. I’m thinking it might help me with that, too. In my line of work, creativity is important and if Prozac will help me with that, I won’t feel as much pressure on the job.”

For the woman with the three properties, we worked through that with minimal use of medications. I’m not proud to say that, for the man who desired creativity, I stared at him blankly when he was done speaking.

It’s important to know yourself. As I understand it, it usually takes at least a lifetime to learn about yourself. Even then, most people never know themselves completely by the time they die.

Learning about yourself helps you recognize how you could do things better or differently. We all have our weaknesses. They exist, even if we wish they didn’t. Everyone else sees them, even though we don’t.

There are many ways to get glimpses of our blind spots. If we’re willing to linger a bit when we catch these glimpses, we have the opportunity to make ourselves more awesome.

However, it’s hard to linger because these glimpses often occur when we’re angry or annoyed. Maybe you make an executive decision for something to happen and a lot of people don’t like it. Maybe you learn that not as many people liked or supported you when you thought they did. Maybe you wish that an institution or a group of people would write or say nice things about you, but they don’t.

How it burns!

These are all opportunities to get to know yourself a little better:

  • What emotion am I experiencing?
  • What happened that led me to feel this way?
  • What do I think the truth is?
  • Is it possible that what I think is true isn’t actually true?
  • What questions could I ask to learn more?
  • What do I think might happen if I start to ask questions?
  • What would it mean to show ignorance?
  • What would it mean if I were wrong?

Wherever you go, you bring yourself with you. Even if you do not yet have any interest in learning about youself, that doesn’t stop other people from learning about you. It is much more humiliating when everyone else knows you much better than you know yourself.