Nonfiction Reflection Systems

The AirBnB Listing.

Had the AirBnB listing included more details about the neighborhood, we probably would’ve stayed elsewhere.

It was lovely: It was a cabin off of a gravel road in a rural area. Fragrant trees towered over the hot tub surrounded by manicured gardens bursting with blossoms of red, peach, and violet. Chirping crickets lulled us to sleep and the songs of warblers and sparrows heralded the rising sun.

The AirBnB listing didn’t advertise the faded truck driving through the neighborhood, a red, white, and blue flag the size of a queen-size sheet flapping from its bed: “STOP THE BULLSHIT: TRUMP PENCE 2020”.

The AirBnB listing didn’t highlight the hand-painted signs leaning against the campers that faced the highway:

     Trump is
     United states back to real

The AirBnB listing didn’t describe the tree farm down the street. The scarecrows guarding the short saplings wore plain white robes adorned with white hoods. Were we reading too much into that?

When we saw the roadside diner, we kept driving because we saw that the first letter of the three words in the name were all K. Maybe locals called it the “Triple K”; maybe it was just meant to be “kute”. Maybe we were reading too much into it.

Nonetheless, we felt like we were in the minority, that we were outnumbered, that we didn’t belong there.

Though we speak impeccable American English, we made a point of greeting people first so they could hear that we were Americans, even if some people don’t think we look like them. We said please and thank you, we smiled and deferred, we were demure. We were model minorities.

Why did we do that? Why did we assume that all people in regions that support Trump would not want us there? Is it fair to assume that all people who support Trump hold racist beliefs? That they believe that we Asians eat dogs, can’t drive, and are socially incapable? Did we think that, if we tried hard enough, we could change their minds?

The AirBnB hosts saw my profile photo when I requested to stay in the lovely cabin. I am obviously Asian. They could have rejected my request, but did not. When we met our hosts—an older white couple, one a military veteran—they were courteous and civil. Even though there was a firearm depot down the road, the hosts had posted signs on their property stating that guns were prohibited. Didn’t these data points reassure us?

And yet: What did they really think of us? Were they simply willing to take our money, even if they thought we didn’t belong here?

Such is the creeping toxicity of racism: You don’t actually know when you should be worried, so you always worry. Even worse for those with darker skin, if you can’t be sure when your life is in danger, then you always feel like your life is in danger.

The toxicity of racism creeps in both directions: Those white individuals who fear that people of color will outnumber, replace, or dominate them also carry this chronic cognitive cargo, even when surrounded only by white people.

Despite climbing mountains bursting with wild flowers, admiring snowy peaks of nearby volcanoes, and appreciating the shade of pine and spruce, we never fully escaped the worry about racism or the worry that we were reading too much into things.


Medicine Nonfiction Observations Reflection

Work Spouses and Mentors.

I recently had dinner with a good friend. He and I trained together at the same time and he has since gone on to become a super fancy academic psychologist on the East Coast. Over dinner, he opined that an optimal work situation includes two components: a “work spouse”, and a mentor.

“The work spouse is at the same level as you—same training, same work,” he said between bites of lasagna. “And a mentor is a mentor.”

“Yes!” I exclaimed. My mind recalled the respect and affection I had for all of my “work spouses” over the years:

  • Chris and Sohan both made me laugh, helped me with the endless scutwork to get me out of the hospital, and helped me keep things in perspective when we were interns.
  • Ryan, Scott, and Ryan also made me laugh, provided thoughtful clinical consultation, and gave sage personal advice while we became less human during residency. There was even that time when we were all on call on the same night, but at different sites… and we called each other sometime between 3am and 4am just to check in. Ryan and Scott also taught me how to throw a football; the other Ryan taught me how to improve my storytelling.
  • Sharon made me laugh during fellowship (do we see a theme here?) and provided an international perspective about community psychiatry. Sharon and her husband also invited me to experience a Passover Seder.
  • Joe made me laugh (…) and helped me cope with the stress and discomfort of 15-minute medication appointments. He also validated my opinion that such a model neither matched my values nor allowed me to provide the care that I believe people deserve.
  • Craig also made me laugh, helped me think through difficult clinical quandaries, and also validated the privileges and challenges associated with working in a jail.

In two cases I didn’t have a “work spouse”. They were both medical director positions… and in both instances I was the only physician who worked in those parts of the organizations. Let me be the not-first to say that, yes, doctors think about and approach things differently. Sometimes it’s useful; sometimes it annoys the heck out of everyone else. It’s often isolating: On the one hand, sometimes people elevate an opinion simply because it comes from a doctor; on the other hand, sometimes people disregard an opinion because the doctor’s perspective seems irrelevant. Both reactions are problematic.

“I haven’t had a mentor in years,” I said after a long pause. “Maybe that’s because there aren’t a lot of Asian women who work in public sector psychiatry?”

That might be true, but I don’t know that for sure (though, as I have progressed in my career, it seems that there are few psychiatrists who choose to work in public sector, non-hospital, non-clinic settings). My mind ran through the people I have considered mentors:

  • Randall, a gastroenterologist, taught me in medical school how to remember that patients are people.
  • James, a psychiatrist, highlighted the intellectual rewards of psychiatry and is arguably the person who persuaded me to pursue a career in psychiatry instead of internal medicine.
  • Matthew, an infection disease physician who longtime readers recognize at the Special Attending, demonstrated the intellect, kindness, and humanity that we want our doctors to possess. He was one of the few attendings I worked with who brought cold water and warm blankets to patients when they requested them.
  • Dick, a pharmacist, not only knew a ton about medications, but also dispensed Taoist wisdom about how to manage people in distress… including ourselves.
  • Deb, a psychiatry residency program director, demonstrated a steady grace and cool serenity despite the tumult of resident distress. I still recall and admire her steady support and faith.
  • Brad, a psychiatrist, taught me that “patients are called patients because they are patient with us” and that, while we have the privilege of helping people, we should discard any “rescue fantasies”. The true heroes are the patients, not us.
  • Sarah, a psychiatrist who worked as a medical director for a major US city, validated my interest in working at the boundaries of fields and also encouraged me to apply for positions that I thought were out of my league. “If something scares you, you should do it.”
  • Van, the only boss I’ve had who is both a psychiatrist an a person of color, continues to provide sage career advice and said that words, “Everyone should receive high quality psychiatric care, whether they go to a nice office on Park Avenue or if they sleep on a bench.” Just knowing that someone else thinks that makes me feel less lonely.

At the risk of sounding woo-woo, though, we can all find mentorship everyday. Everyone can be our teachers if we are willing to be students. I think about the bus driver who greets everyone with a warm smile, but has no qualms about commanding—firmly, but politely—a rider to stop harassing vulnerable people who are also on the bus. Consider the finance officer with no formal authority who speaks up during a meeting to advocate for more transparency in fiscal affairs. What about that coworker who picks up the litter in the lobby when he thinks no one is watching? Because he wants to leave a place looking better than it did when he walked in?

If you are fortunate to have a work spouse, bring him or her a treat. If you don’t think you have a mentor, remember that there are others who can provide guidance and inspiration.

Education Lessons Nonfiction Policy Reflection Systems

What I Learned in Government.

It’s been nearly four months since I posted something here. Don’t be fooled: The lack of words here did not mean an absence of word salads tossing about in my head.

I recently resigned from my job. (All The Things related to that contributed to my silence here.) My job had two parts: One involved administrative work as the behavioral health medical director for local government; the other involved direct clinical service in a jail. I was in that job for over five years. It took me about two and a half years to figure out what an administrative medical director does. (As the process of becoming a doctor involves frequently feeling incompetent, this discomfort wasn’t new to me.) Now that I’m on the other side of this job, here’s what I’ve learned:

I believe government can do good things. You know that stereotype that government employees are lazy? I did not find that to be true. Every organization has a proportion of staff who do not seem motivated or interested. The proportion, in my experience, does not seem higher in government. If anything, many of my colleagues came to government with eager hopes of improving the community. They came in early, stayed late, and worked on weekends. They convened groups with opposing viewpoints, advocated for different populations in the region, and expressed dissent to people in power. They sought out and willingly worked on complicated problems. They demonstrated the humility that comes with the realization that tax payers are funding their salaries.

I do not enjoy the game of politics. Some people love it! They enjoy the contests of status, flaunting their connections, and attacking perceived enemies in public forums with the brightest of smiles. Sometimes people asked me to speak, not because they cared about the content of my words, but because of my credential as a physician. (“Let’s trot out The Doctor.”) I grumbled about “perception management”; often it seemed that the surface sheen mattered more than the substance underneath. (On the other hand, it is likely that my glittery MD credential is what allowed me to say to superiors that poop will never develop a patina. It is unfair that systems often value specific people more simply because of the letters after their names.)

Government work has made me both more and less patient. It takes time to elicit ideas and information from “stakeholders”, community members, and others. People want to and should be involved if a policy or program will impact their lives. They share perspectives that government never thought to consider. I respect that process. I am less patient with the nonsense people and systems can generate to subvert fair processes. Some people are more prone than others to misuse power. That’s hard to watch in a system like government, which has access to and authority over so much money… and, in our current system, whoever has more money almost always has more power.

I learned a lot about laws and regulations. I came to appreciate the value of regulations, though they tend to address the lowest common denominator. Government spends most of its time aiming low to define the floor instead of inspiring people to elevate the ceiling. (I wrote more about this here.)

Government administrators forget what happens in direct service. Though many people in government once provided “front line” services—as attorneys, social workers, counselors, activists, whatever—many of them seem to forget the challenges of systems that are intended to help people. This includes the thousand little cuts of too much paperwork and the major crises of people dying due to missing or underfunded services. My opinion that all medical directors should routinely provide direct clinical service has only gotten stronger with this experience. Someone has to inform the others at The Table what’s going on outside.

Systems are made of people. Contemporary discourse often focuses on systems, not people… but people make up systems (i.e., individuals create, operate, and maintain systems). As such, single individuals can still have significant impacts on systems. This includes grinding things to a halt… or breathing life into new programs. (This is where political gamesmanship can be useful.) The hierarchical organizational chart can lead people who are “lower” to think that their efforts don’t matter, but that’s simply untrue. Systems can change because people can change… whether that’s because people actually change their ideas and behavior or people in certain positions leave.

I am deeply grateful for the opportunity to work in government. I never thought I would work as a civil servant (and, in fact, there was a time when I said I’d never work for government… which is why I’ve stopped making five-year plans). If for nothing else, now that I’ve been on the inside, I can use that experience and knowledge on the outside.

The outside suits me better. So it’s time to go back.