Medicine Observations Reflection

Dr. Handsy.

Note: I’ve felt pretty bummed out for the past two weeks, much of it related to the behaviors and opinions of the US federal government. Epictetus commented that

We are only enraged at the foolish because we make idols of those things which such people take from us.

which, yeah, is all fine and good, but I have yet to achieve a level of wisdom where I do not permit others to steal my peace. I find it hard to write when I’m unsettled.

A female friend, who is not a physician, recently asked me, “Do you find that, in your position, men treat you differently? Meaning, do they show you the same kind of respect that they show their male colleagues?”

The group of medical directors were seated around the table. The meeting was supposed to go on for six hours. While I was not the only female in the room, I was the only female medical director in that cohort.

Around hour two, the medical director seated to my right, a man with whom I had no relationship, made an emphatic statement to the group. While doing so, he leaned over and grasped my bare right arm with both hands. One hand gripped my bicep; the other hand wrapped around my forearm.

In my surprise, my eyebrows furrowed and I turned to look at him. Before I could ask him to let go, though, he had already released my arm and his palms were flat against the tabletop. The large gemstone on his left ring finger reflected the fluorescent lights overhead.

I smirked to myself. Did that just happen? Should I say something now? Maybe he won’t do that again. That was weird.

Around hour four, he used the back of his left hand to deliver a brisk tap to my right tricep.

“Hey, what does [acronym] mean?” he whispered as the group continued its discussion.

With urgency I pulled my arm into my lap. After murmuring my answer, I scooted my chair away from him.

It’s too late again for me to say something. Boo.

Around hour five, he rested his bejeweled left hand onto my right forearm while finishing his gallant comment, “… as Dr. Yang said earlier.”

Another man had already begun to speak as I yanked my arm away. Glancing at Dr. Handsy, I summoned forth the Ice Queen and hissed, “Please stop touching me.”

Oh, the look that Dr. Handsy shot at me! It was as if I had kicked his pet dog or spit in his beverage.

I smiled at my friend. “Do they show me the same kind of respect? Many do, but not all.”

Consult-Liaison Education Lessons Reflection

Being Right vs. Being Effective.

“It’s best to avoid confirming their beliefs,” they said, “but you can validate the underlying emotion.”

She was dabbing her eyes with a crumpled tissue already streaked with mascara.

“It’s been two years and I still can’t believe he’s gone. I thought we would grow old together, that he’d get to see his kids graduate from high school.”

“The sadness still feels overwhelming.”

“Yes,” she whispered before bursting into tears. “When will I stop feeling so sad?”

He avoided eye contact while his leg bobbed up and down.

“I feel so anxious, like I’m paranoid. It used to be that I only felt paranoid when I was high on crystal meth, but now it’s all the time. It’s like people are watching me all the time, like they want to know all my business or something.”

“It’s exhausting to feel so anxious all the time.”

“Oh my God, YES. I’m so tired, but I can’t relax.”

“I didn’t know what to say to my wife. She didn’t deserve any of this. I tried to stop, and I did for a few weeks, but then I’d download more of it. My wife was the one who answered the door when the police came to seize my computer. I would do anything to not have this problem; I know how many people it hurts.”

“You feel a lot of shame about looking at child porn.”

His face flushed and his voice quivered.


She heard every word, but her gaze was fixed to something on the other side of the room.

“I can’t. I’ve already said too much. I can’t. I can’t. They know, they will know, they already know everything. I can’t. It’s in the lights, it’s in the ceiling, it’s in the sky. It’s everywhere. I can’t. They will know and they will know through the lights—”

“You’re scared that something bad will happen if you tell me the story.”

“Yes! And I want to be strong, I don’t want to be scared.”

“The whites are better than the Asiatics—”

“Let me ask something else—”

“—and there will come a day when all the races will submit to us—”

“—I’m going to walk away if you keep talking about this—”

“—even people who went to a lot of school like you. I’ll remember that you were helpful, but you are still just an Asiatic—”

“—okay, I’m going now.”

“But Doctor! You know what I say is true! C’mon! Why won’t you talk to me about this? You’re not being a good doctor….”

“You also have to respect your own limits,” they said. “Sometimes you want to show that just how right you are, but it’s much more helpful to be effective. And sometimes it’s best for everyone if you end the conversation when you’re no longer effective. You can always try again later.”

Education Medicine Nonfiction Reflection

A Week in School!

I spent the past week at a health care ethics seminar. Here are some reflections:

How lucky was I to spend a week in school? The last time I sat in a classroom for five consecutive days was about 15 years ago. Prior to starting my clinical rotations in medical school, I was a professional student: There were 18 years between kindergarten and my second year of medical school. I got really skilled at sitting in classrooms, listening to people talk at me, and organizing the information for either tests or real-world application.

I’ve recognized the privilege of attending school. I don’t think I appreciated the depth of this privilege until this past week.

Different perspectives makes for rich learning. Most of the students in this seminar came from three professions: Chaplains, nurses, and physicians. There were some social workers, as well as an attorney or two.

There were further divisions within those groups: Some people were professionals within the military; others came from Catholic hospitals; multiple medical specialties were present. Most of the people there were already participating in ethics committees.

The different perspectives that each profession, specialty, and individual brought were useful. Decisions by committee can be onerous (cf. the pain of some meetings), but discussing and learning within committees is often humbling and fascinating. My classmates brought up ideas and arguments that I would not have considered.

One wonders if these rich discussions occur because we know our time together as a group is limited. In standing meetings in our usual jobs, we sometimes get accustomed to who says what and why. We might also face formal or informal consequences for speaking up (or not speaking up). In a week-long seminar, what have you got to lose by sharing your thoughts?

On not speaking up. As both a student and physician, I continue to receive feedback that I should talk more. (Given how much I blather here, one might find this surprising.) When I was a student, sometimes teachers thought I didn’t care about the topic. (Usually untrue.) Sometimes they thought I was shy. (I’m not, though people who haven’t gotten to know me might think otherwise.)

These days, sometimes people wish I would speak up to demonstrate my expertise. Sometimes I get the impression that some people want to know what I’m thinking, but when I don’t speak, they believe I’m withholding information on purpose. (Rarely true.)

There was plenty of dialogue that occurred between teacher and student and between students during the lectures. I said little. The admonitions from my past (and present) echoed in my ears: “You’re not talking! You’re not contributing to the group! Why don’t you say something and help out?”

Honestly, I think I’m just a slow thinker. It’s not that I don’t have opinions; I just find myself thinking about multiple perspectives at the same time. This muddles my thoughts. Muddled thoughts often leads me to produce incoherent speech. While I’m slowly clarifying a single line of thought, others who are able to organize their thoughts faster have raised their hands and are ready to speak.

Health care ethics isn’t limited to death and dying. Most of the discussions we had during the seminar surrounded death and dying. For example: A child is in a coma in the intensive care unit. The medical team wants to proceed with further interventions and treatment that has a 50% chance of recovery. The parents of the child want to withdraw treatment, which means imminent death. Discuss.

I imagine that most ethics consultations in the hospital are related to death and dying. But what about all the other ethical quandaries that are not as “glamorous”, but occur more frequently?

Like informed consent for medications. How much informing is “enough”? How much detail of the risks, benefits, and alternatives should we offer? If someone doesn’t want the information, but wants the treatment, is that a valid consent?

When I was a resident, one of my attendings commented in half-jest, “A common problem with informed consent is that by the time someone is truly informed, they are not able to provide consent… and when someone consents, they are not truly informed. Consider someone who is experiencing CPR: The chest compressions, the mouth-to-mouth breathing, the ribs breaking. That person is completely informed about CPR now… but he can’t consent. But when we obtain consent about CPR, that person usually has no idea what happens during CPR.”

Involuntary treatment is a big deal in psychiatry (as it should be). Sometimes we don’t seem to devote sufficient attention to all of its ethical issues.

The value of teachers showing vulnerability. Some of the speakers at this seminar take care of patients. They offered real clinical examples of ethical quandaries (e.g., a patient who doesn’t want to know her diagnosis, even though the physician believes that the patient should know). Those discussions were the most compelling because these teachers had opinions about what to do, but were not sure and still are not sure if they did the “right” thing.

I admired the thoughtfulness and humility of these speakers. Ambiguity is present in all of medicine. Sometimes we—all of us, regardless of our role—want a clear, concrete answer, but it doesn’t exist. Sometimes people craft an answer to reduce the motion sickness they feel while floating on the sea of ambiguity. It takes courage to recognize that sometimes there is no anchor, that the clouds are blocking the stars, that we don’t know where we are or what to do next. We just do the best we can with the information we have at the moment.

The value of pithiness. Several of the instructors seemed to speak solely in aphorisms. It didn’t matter how muddled or disorganized our questions were; they reformulated our questions with wisdom and clarity and provided concise answers.

I wish I could do that all the time.

Each instructor highlighted the importance of clarifying the ethics consultation question. This idea was also drilled into our minds as psychiatry residents when we were learning how to do hospital consults. What is the question? It doesn’t matter how great the answer is if it doesn’t actually address the question. And sometimes we don’t know what we’re asking.

Pithiness comes from clear thinking. Clear thinking comes from understanding the issue at hand. We don’t understand the “issue at hand” unless we ask questions.

Of course, these instructors have been thinking about ethics for years. They have likely heard our questions or some variant of them before. The various moral frameworks (e.g., utilitarianism, deontology, virtue ethics, etc.) are novel to us, but not to them.

It also takes time to think clearly. The time pressures inherent in clinical medicine contribute to muddled thinking or, in the worst case scenario, not thinking at all. This is yet another reason why I was grateful to attend this seminar: There was time to think, reflect, and consider the “bigger” picture of the work we do.

As I’ve noted before, the more experience I get, the more I realize how much I don’t know. (It’s disturbing.) This is why I now value more how to think, rather than what to think. The content changes over time as psychiatry makes (slow) advances. Knowing how to apply this information in the service of caring for patients is paramount.

For those of you interested in health care ethics, the primary paradigm this seminar used is called the “four boxes“. Look over my Twitter timeline for more comments about the seminar (though I stopped sharing much after day three, only because my mind felt full).