Blogosphere Nonfiction

The “Best Of” 2017.

There are ten days left in 2017.

This is the third iteration of my blog. I started this one in November 2010. The first iteration of my blog started in November 2000. That means I’ve been writing online for 17 years (???), though I fled the internet for about two years.

In looking back over what I wrote in 2017, these are the posts from this past year that had the most visits:

Disappointment. “My cohort graduated from our psychiatry residency almost ten years ago. The level of frustration and disappointment we’ve all experienced within the past two years is striking.”

My Seattle Times Op-Ed about #MeToo in Medicine. “The senior psychiatry resident at the University of Washington School of Medicine warned me ahead of time. She laughed as she said, ‘He’s weird. You’ll get used to him.'”

Thoughts on the Movie “Get Out”. “If you have seen Get Out, this post ponders the role of psychiatry in the movie. (Full disclosure: I enjoyed and recommend the movie.)”

The most popular posts on my blog, though, aren’t from 2017! These are the posts that received the most visits overall:

DSM-5: Schizophrenia. This post is a brief discussion about how DSM 5 defines schizophrenia. (I wrote about other diagnoses, too, but don’t know why this diagnosis got the most attention. I have a particular interest in people experiencing psychotic disorders; perhaps that shows?)

Personality Disorders to Difficult Interactions (I). “To be clear, though, just because you have a difficult interaction with someone doesn’t mean that that person has a personality disorder. There are plenty of people without personality disorders who behave in unbecoming ways.”

Do People Choose to be Homeless? “I cannot speak for all people who have ever been homeless. However, I have several years of experience working with people who were homeless and refused housing again and again, as well as people who left their housing and returned to the streets.”

I remain grateful to people who choose to take the time to read my writing. Some of you have been reading since the early days of my first blog; for that, I feel humbled. Thank you.

May 2018 bring you all good health, many blessings, and contentment. See you in the new year.

Consult-Liaison Education Medicine Systems

The Social History.

From the notes I read, it seems that other medical specialties limit “social history” to whether or not someone uses tobacco, drinks alcohol, or uses drugs.

“Social history” is meant to get a sense of the context in which people live. Where do they live? Who do they live with? How did they come to live there? Where did they grow up? What sort of work do they do? How much school have they finished? What do they do for fun? What are the important relationships in their lives? etc.

I almost always start my clinical interviews with the social history. There are several reasons why I do this:

One, it’s a more neutral place to start. My hope is that it will help the person feel more comfortable talking to me. Most of these questions are easy to answer, since many of them overlap with social conversation: Where do you live? How long have you lived there? This is also an opportunity to communicate through non-verbal communication: The nodding, the eye contact, and all the other behaviors that show that I’m paying attention and worthy of trust. (“See, it’s not so bad to talk with a psychiatrist.”)

Two, it puts the information the person shares with me into context. If people don’t have a stable place to live, then they have good reason to feel anxious about their safety and exhausted from poor sleep. If someone lives with other people who are struggling with substance use or are often fighting, then this person may not be able to recruit them to help with the tasks of daily life. They may not even feel safe staying with them, but don’t have other choices. One can’t expect someone to take medication on a regular basis when they don’t have enough money to buy food.

Three, if people don’t want to talk to me for whatever reason, the way they stop the conversation is useful information. Sometimes people are paranoid for a variety of reasons—some based in reality, some not—and they shut down the interview. Sometimes people want to talk to me, but they’re exhausted and ask me to come back later. Sometimes people don’t like something about me: my hair (it’s noteworthy how some people respond to my hair), my ethnicity, my clothes, my sex, the way I talk. I can’t change most of those things, and how people respond to all that tells me (1) how I can better interact with them in the future and (2) what might be going on that is causing them to respond this way. And sometimes people don’t want to talk to me because I’m not conducting the interview in a skillful way: Maybe I’m coming across as cranky, uncaring, or judgy.

Four, and most importantly, I want the person to know that I view them as a human being. I wince whenever someone immediately launches into their mental health history: “Okay, I have a diagnosis of schizophrenia and I take Zyprexa and Cogentin….” This tells me that this person got the message over time that no one is interested in him as a person; people only want to know his diagnosis and medications. But people aren’t their diagnoses or their medication regimens. All people have hopes and dreams; they have things they want to do and people they want to be. While a summary statement might make the interview more efficient, it matters whether this person volunteers at the animal shelter every week because he loves dogs or whether he stays at home and watches TV all day. This information is valuable, regardless of his diagnosis.

It takes time to get a social history. Short appointments, though, are short-sighted. It’s much faster to generate diagnoses from labs and studies; it’s much faster to write prescriptions than to listen to patients. If physicians don’t get an accurate history, then physicians are more likely to generate wrong diagnoses. Wrong diagnoses, along with no information about the contexts in which people live, lead to wrong interventions. Did anyone then actually save any time?

Informal-curriculum Medicine Nonfiction Seattle

My Seattle Times Op-Ed about #MeToo in Medicine.

The Seattle Times published an op-ed I wrote! Their editorial staff provided the title, #MeToo in medicine: ‘Who would believe a trainee?’

I wonder: What if I had a different byline? Would the Seattle Times have published it if I worked as a nurse? medical student? medical assistant?

What if I worked as a janitor in a hospital? Or in housekeeping?

What if I waited tables? worked in retail? had a job that is “off the books”?

The last sentence in my op-ed is “I was fortunate, but not all women are.” I was fortunate in that I had support from supervisors and colleagues, and that the psychiatrist in question didn’t do anything worse.

I remain fortunate, though, in that I have the privilege to be able to share this story to a wider audience. I have access that other people lack. And those are the people we should consider about when we talk about “#MeToo”.

The senior psychiatry resident at the University of Washington School of Medicine warned me ahead of time. She laughed as she said, “He’s weird. You’ll get used to him.”

When I first met with him, the psychiatrist lazily spun in his chair, his left hand tucked into his pants, his thumb hanging out. After he told me his expectations as my supervisor, he patted my right thigh as he ended the meeting.

I spent one day a week training in his clinic. He often put his hand on my shoulder. If he sat near me, he extended his arm to pat my leg. When I sat far from him, he crowed compliments in front of patients and other staff: “Dr. Yang is one of the best residents who has ever worked with me!”

He began to send emails to me at all hours of the day and night. They stopped referring to clinical research and developments; now he wrote of art, history and music that he thought I would enjoy. Some of the timestamps on his emails were near 2 a.m.

“Do as I say, don’t do as I do,” he chided in his emails. “Good night.”

My discomfort increased over time, though I wondered if I was overreacting. After all, didn’t another resident tell me that he was weird? She didn’t seem distressed with his behavior. Maybe I was too sensitive.

I asked two other supervisors, both psychiatrists, for advice. The male psychiatrist was angry and swift in his response: “You have to tell your residency director. This isn’t right.”

The female psychiatrist wavered. “I don’t know,” she said after a long pause. “It’s up to you if you want to say something. It could turn into a ‘he said, she said’ issue.”

She had a point: Who would believe a trainee over a tenured professor? Would he retaliate? How would this affect the rest of my training?

I decided to talk with him first. My request seemed reasonable: “Could you please stop touching me and stop sending emails to me that are unrelated to clinical work? I feel uncomfortable when those things happen.” I rehearsed.

The next time I saw him, he greeted me with a pat on the shoulder. I felt my face flush as I stammered, “Could you please stop touching me? It makes me feel uncomfortable.”

He paused, then smiled. “Why didn’t you tell me sooner? It’s not that big of a deal. I’m just being friendly.”

It was a big deal: He stopped talking to me entirely when we were in front of patients. He stopped teaching me. At what would become our last meeting together, he refused to acknowledge my concerns about a clinical issue. It seemed like he was trying to pick a fight with me. We fell silent. He looked at me with amusement. I glared at him.

“Are we done?” I still felt like I needed his permission to leave.

“Yup!” He grinned. It was clear I had to talk with my residency director.

She believed me. She was swift and immediately pulled me from the rotation.

One of my fellow trainees, a robust man who played football in college, was assigned to work with him for the following six months.

My fellow colleague believed me. He was swift. He objected and asked for another rotation, stating that he didn’t feel comfortable working with a physician who had mistreated another trainee.

The psychiatrist ultimately left the institution, following an administrative leave.

Sexual harassment occurs in every profession, even medicine. To stop this, we need as many people as possible — men, women, colleagues, advisers and leaders — to support women and act swiftly when these events occur. I was fortunate, but not all women are.