Author: Maria Yang, MD

Categories
Lessons Medicine Nonfiction Reflection

Centered and Ostensibly Serene.

The nights from that time run together in my memory: The cuffs of my scrub pants getting caught on the heels of my clogs because my pants were sagging; stuffing dry graham crackers I stole from the nursing stations into my mouth at 4am to stay awake while writing notes; what seemed like my pager buzzing against my hip every five minutes; feeling the enormous specter of unending work overtaking me and wondering if I had any remaining skills to gird myself; recognizing the sadness and anger churning within me as I witnessed and listened to tragedies, then shoving the emotions away because there just wasn’t any time I didn’t want to cry I just needed to get through a few more notes I just wanted to sleep of the mistaken belief that if I ignored how I felt, I would be okay.

“Hey, you! You coming to talk to me?” The Big Man shouted.

“No,” I replied. “I’m going to talk with your neighbor.”

“What? But then you’re gonna talk to me, right?”

“I have two other people to talk to first, but, yes, I will talk to you after I talk with them.”

“But you’re gonna talk to me, too, right?”

“Yes.”

I had just finished introducing myself to The Patient and was asking his name when The Big Man, just three feet over and behind a reinforced steel door, started yelling at me: “You lying bitch! You said you’d talk to me!” The Big Man began pounding on the door with his big fist.

The banging reverberated throughout the entire unit. Another inmate on the other side of the unit began banging his door in protest.

I sighed and rolled my invisible eyes.

BANG BANG BANG “I’m sorry,” I said to The Patient. He nodded and came closer to his door. I did the same. “I will try to keep this short, but I do want to hear what you have to say.” BANG BANG BANG

BANG BANG BANG “It’s okay,” The Patient replied. BANG BANG BANG

BANG BANG BANG “Are you in any physical pain right now?” BANG BANG BANG

BANG BANG BANG He tilted his head, telling me without words that he couldn’t hear what I said. BANG BANG BANG

BANG BANG BANG “Are you in any physical pain?” I asked again, nearly shouting. BANG BANG BANG

BANG BANG BANG “FUCKING BITCH! YOU SAID YOU’D TALK TO ME!” The Big Man shouted. BANG BANG BANG

BANG BANG BANG “My feet,” The Patient answered, raising his voice. “I have blisters.” BANG BANG BANG

He pointed down at his feet. The puffy blisters were evidence of ill-fitting shoes. The Patient reached down, grabbed a sandal, and threw it in the direction of The Big Man. BANG BANG BANG “Stop it, man.” BANG BANG BANG I watched it sail past me and bounce in front of The Big Man’s door.

BANG BANG BANG “Do you want me to get that for you?” I asked, recognizing that the pair of sandals were now separated. BANG BANG BANG

BANG BANG BANG The Patient chuckled. “No,” he answered, a small smile on his face. “I only had one, anyway.” BANG BANG BANG

BANG BANG BANG “Do you want another pair?” BANG BANG BANG

BANG BANG BANG “YOU WANT ME TO STOP DOING THIS? THEN YOU NEED TO FUCKING TALK TO ME, BITCH!” BANG BANG BANG

BANG BANG BANG “No, I’d rather have a pair of socks,” The Patient replied. BANG BANG BANG

BANG BANG BANG “I’ll get you a pair.” BANG BANG BANG

Despite the increasing rate and volume of The Big Man’s fist hitting the door, The Patient and I both ignored him. It was clear that we had both mastered this skill at some point earlier in our lives. The Patient made it look effortless; his face was calm and his voice was even. Even though he had thrown his shoe, his limbs did not become tense again.

The Patient told me about his health, asked me to call his counselor, and, when I ended our conversation only a few minutes later due to the noise, he thanked me.

BANG BANG BANG “No, thank you,” I said, smiling. “I appreciate your patience. I will try to talk with you again later. Maybe we will have better luck.” BANG BANG BANG

I didn’t look at The Big Man as I turned away. He stopped banging when I had walked a mere ten feet away from them. I then rolled my actual eyeballs. I knew that was when he would stop.

The stress of internship and residency most certainly contributed to my current abilities to stay centered and ostensibly serene in the midst of chaos. We all had to learn how to manage ourselves in the face of death, disease, and distress. Sometimes our efforts were successful; sometimes we felt embarrassed because we believed our efforts failed.

I learned how to show myself more kindness during residency. This wasn’t a conscious choice. Three things happened:

  1. In learning how to provide psychotherapy to others, I learned how to apply these skills to my own life.
  2. I couldn’t contain the sadness and anger that churned within me as I witnessed and listened to tragedies. Sometimes I cried in the bathroom. Most of the time I wept at home.
  3. People—and more often than not, patients—demonstrated grace and kindness during these moments of heartbreak. They often exhibited a capacity to accept their circumstances and show compassion, despite their physical or psychological pain.

I felt my chest fill with grief as I walked away from The Patient and The Big Man.

What happened to The Big Man? When and how did he learn the only way to get his needs met is to destroy silence?

What happened to The Patient? When and how did he learn to show grace and respect in the midst of hateful noise?

I didn’t cry because, this time, I didn’t shove the emotions away.

Categories
Lessons Nonfiction Reflection Systems

Phone Calls.

I don’t miss making the phone calls in the middle of the night.

“Hi, this is Dr. Yang calling from the Psychiatric Emergency Service. May I speak to Mr. or Mrs. Doe?”

“Yeah, this is Mr. Doe,” he’d reply, his voice thick and slow with sleep.

“I’m sorry to call so late. Your son is here at the hospital.” Take a breath and slow down for the next part. “He’s alive and doing okay at this moment”—I quickly learned that it is important to say these words at the start of the call—“but I hope to get some information from you about him.”

I have marveled at the grace people have extended to me during these conversations. Sometimes family members have grown accustomed to these 2am calls and their voices sound not only physically sleepy, but also psychologically exhausted. Sometimes family members have never received this phone call, but their voices remain calm with only the occasional quaver while they talk.

These days, it’s “Dr. Yang calling from the jail”. Though I’m not making these phone calls in the middle of the night, it is questionable that these are better phone calls.

It is a blessing when family members are still involved, when there’s someone I can call. The person in question is usually a male in his 20s. He often has reached desirable milestones: Maybe he just graduated from high school or is in college. His primary health issue is the mental health condition—often bipolar disorder or schizophrenia—and he’s otherwise healthy. He is often able to tell me about a family member who loves him, even if what he tells me doesn’t make a lot of sense in the moment.

For so many others under my care, there’s no one to call:

  • “They died.”
  • “I don’t want anything to do with them.”
  • “I don’t know where they are.”

Sometimes the person in question is much older. In some ways, these phone calls are more tragic:

  • “I’m in my 70s now and I’m the process of moving my wife into a memory care facility….”
  • “My husband has already died and I worry who will take care of my son when I go. He still needs a lot of help.
  • “Thank you for calling, Doctor, but it doesn’t seem like anything will change. I’ve been doing this for almost thirty years now.”

I marvel at the grace people have extended to me during these conversations, too. For some of these family members, they’ve had dozens of these conversations with many other doctors, nurses, counselors, and social workers. They know what questions I will ask; their answers are succinct because others have interrupted them in the past; they have lists of information already prepared to send.

Almost without fail, after I thank these family members for their help and then comment on the difficulty of the situation, they cry. Sometimes the sobs that escape their throats surprise them.

“I’m sorry,” they mumble. I can hear them wipe the tears from their faces with haste.

I’m sorry that we can’t do better for your son. I’m sorry that the science hasn’t advanced enough that we can prevent this from ever happening to your son ever again. I’m sorry that your son is in jail when he should be in a hospital. I’m sorry that your hopes and dreams for your son haven’t come true. I’m sorry that few people know the depth of the worry you have for your son. I’m sorry that these systems fail you and your son. I’m sorry that your love for your son isn’t enough to save him from these systems.

“Please, don’t apologize,” I say instead.

I wonder why.

Categories
Homelessness Lessons Medicine NYC Observations Reflection Seattle

The Kind of Energy We Send Out to the World.

I have been writing; I just haven’t posted anything here. These days, it seems that we cannot escape increasing types of noise and their loud volumes. It’s not all noise, but the signals are overwhelming.

It was a busy teaching week for me: I had the privilege to speak at two community clinics and a public hospital. In all three presentations I commented on the tension between “the system” and our efforts as individuals. When we’re trying to provide care and services to individuals, sometimes the constraints of “the system” interfere with our efforts: Sometimes fiscal concerns reign supreme; sometimes the bureaucracy is inflexible; sometimes the system does not have noble intentions. We grumble, we get angry, we feel helpless.

When we’re trying to design “the system” to provide care and services, sometimes the constraints of people interfere with our efforts: Sometimes there aren’t enough people; sometimes people make mistakes; sometimes people do not have noble intentions. We grumble, we get angry, we feel helpless.

The two, of course, are related: People design systems. People work within systems. People can change systems.

People also have values. Sometimes we find that our values clash with those of the systems we work and live in. That doesn’t mean that we must defer to the values of the system. It takes courage to resist. To show our values to the world without flinching is an act of bravery.

While speaking, I told a story about my first boss when I finally started working as an attending psychiatrist. Our jobs included working with people who were homeless in New York City.

“I want people who don’t have a place to live to get excellent care,” he said, perhaps talking more to himself than to me. “Good care shouldn’t be limited to people who can afford to pay a psychiatrist who works out of a plush office on Park Avenue. People who don’t have money should have access to and get good care, too.”

“These are choices under our control,” I said to the audience yesterday, perhaps talking more to myself than to them. “Even though system pressures are very real, you can choose to give good care to the people who come here for help. You can treat people with dignity and respect, particularly if they are people of color with very low incomes. They might not get dignity or respect elsewhere.”

Perhaps my exhortations sound naive. Perhaps cynicism will triumph over virtue. However, I refuse to embrace cynicism. Cynicism makes for terrible company. Life is already full of challenges; we do not need negative soundtracks to accompany us as we travel through life. What we do affects others. What we say can inspire others.

We have responsibility for the kind of energy we send out to the world.

Categories
Education Lessons Nonfiction Reflection

Uncomfortable Thrill.

When I walked through glassware sections of stores as a child, my body buzzed with distress and delight. There were only two ways to ease this anxious discomfort:

  1. Fling my arms out and knock over all the glass to see, hear, and feel the pieces shatter; or
  2. Keep my arms tightly by my side and ensure that nothing above the soles of my shoes touched any objects in the store.

I always chose the second option. The urge to fling my arms out to knock over crystal and glassware has diminished with time. If I’m honest, though, the uncomfortable thrill persists.

That same uncomfortable thrill pulsed through me when the loaded guns rested in my hand.

It didn’t matter that I received a private didactic (with a white board![1. The white board didactic included four rules: (1) All guns are always loaded. (2) Keep finger off trigger until ready to fire. (3) Be aware of target and what’s behind it. (4) Don’t point at anything you’re not willing to destroy.]) about gun safety from someone I know and trust (who also happens to work as an emergency physician). It didn’t matter that we were at a pistol range where safety was paramount. It didn’t matter that I had close supervision for my first experience in shooting firearms.

The paper target revealed that my initial shots were the most accurate; the subsequent shots often drifted farther and farther from the target. Maybe my hands and arms suffered from fatigue. Maybe my uneven breathing made my body needlessly tense. Maybe my safety glasses got too foggy from perspiration.

Maybe it was the National Geographic article about a young woman’s face transplant due to a self-inflicted rifle wound that I had read just the day prior. Maybe it was the imagery of the assassination of President John F. Kennedy and the later murder of Lee Harvey Oswald that I saw at The Sixth Floor Museum.

Maybe all the stories I remembered from my work as a psychiatrist freaked me out.

Maybe it was all the stories I never heard or have yet to hear.

It happens so fast: Finger is off the trigger. Finger then rests on the trigger. Finger flexes.

BANG!

The bullet is gone. My body lurches with the recoil. The bullet casing bounces off my shoe. I only see the puff of pewter smoke when I lower my arms.

  • How much time passed between the time she loaded the gun and when she fired it at her chest?
  • Did she hesitate before she put her finger on the trigger?
  • How many times did he try to pull the trigger before putting the gun down?
  • Did he ever put his finger on the trigger before he pulled the barrel of the gun out of his mouth?
  • Did she ever touch a gun before the day she tried to kill herself with one?
  • Did he imagine what the BANG would sound like within his skull?

The power of the weapons spooked me.

My hands weren’t shaking, but my fingers could not push the 9mm bullets into the magazine. My hands felt weak.

More than once I walked away, pulled the safety glasses off my face, wiped the sheen of sweat off my forehead with my forearm, and then jumped up and down several times.

I never felt any urge to turn the guns on myself, though the uncomfortable thrill reminded me that I could. Others who are unable or unwilling to resist that uncomfortable thrill could indulge that urge, whether against themselves (more common) or against others (much less common). The uncomfortable thrill may not feel so uncomfortable when one is intoxicated. Or angry. Or hopeless.

It could happen so fast.

Yet, I quickly recognized the appeal behind shooting. Guns are tools. The anatomy and mechanics of firearms are interesting. Learning how to aim and hit targets with high accuracy is satisfying and rewarding. Achieving mastery over such powerful tools is thrilling.

I am grateful that I had the opportunity to learn how to shoot pistols. It was fun, though I must confess that it was not as fun as I had anticipated. Thoughts of death and injury from suicide rarely left my mind, which added elements of stress and sadness. Jumping up and down and taking deep breaths could only do so much.

The power of guns freaked me out. It was only the next day that my body finally stopped buzzing with distress and delight.

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Uncategorized

I Won’t Analyze You.

“Oh, you’re a psychiatrist? I hope you won’t analyze me!”

I never know what people actually mean when they say that upon learning that I work as a psychiatrist.

I think they’re[1. I can’t remember an instance when a woman said to me, “Oh, you’re a psychiatrist? I hope you don’t analyze me!” The men who offer that response are almost always trying to make someone laugh—me, them, the people who are observing the conversation.] saying, “I hope you’re not going to spend our time together trying to discern my flaws.” Nobody wants people to seek out, highlight, and exploit their vulnerabilities and faults, so I can understand that. Of course, that’s not what psychiatrists do.[2. Unfortunately, there are psychiatrists who focus on discerning and amplifying individual vulnerabilities. This is abuse of power and is not limited to psychiatrists.]

Anyway, let’s just take the statement at face value—that people hope that I won’t “analyze” them—regardless of what the underlying concern may be. Let’s also assume that when laypeople say “analyze”, they mean “do the things you do when you’re working as a psychiatrist”.

I cannot speak on behalf of all psychiatrists, but let me assure you: If you and I meet in a non-clinical context, I won’t “analyze” you. These are the reasons why:

1. It takes a lot of energy to “analyze” someone (a.k.a., “do the things psychiatrists do when they’re working”). When I’m working, these are the things I’m attending to:

  • What is the person saying? What words does he choose to express himself?
  • How is the person saying what she want to communicate? What is the tone of her voice? What nonverbal signals are present?
  • Is what this person is saying congruent with what this person is doing? What about his facial expressions and other physical movements?
  • What are the underlying or recurrent themes behind what this person is saying and doing?
  • What are the underlying assumptions the person has about himself? How are these underlying assumptions manifesting in what he says or does?
  • Is this person avoiding certain ideas or perspectives? If so, what are some possible reasons?
  • How did these ideas and behaviors come to be? Were they helpful or lifesaving in the past, but are now causing problems for the person? How do these thoughts and behaviors help this person now?
  • Is there something else going on that might explain this person’s thoughts and behaviors? Maybe this isn’t psychological; this might be a medical problem or related to substances (prescribed or not).

While attending to those tasks, I’m also:

  • Doing all the nonverbal stuff—often with intention—to let the person know that I’m listening
  • Saying things and doing nonverbal stuff to help the person feel both physically and psychologically safe in disclosing information to me. If I don’t receive accurate data from someone, I cannot help them as much as I possibly could.
  • Tracking the conversation and putting mental bookmarks in places to either revisit later during this dialogue or in the future (is this the right time to ask that question? how about now? should I phrase it differently now?)
  • Making mental notes of the important details I need to put in my note later
  • Gently (or more assertively, as the case may be sometimes) steering the conversation with questions and comments to make sure I get as much relevant information as possible, given the current circumstances (amount of time, condition of the individual, setting that we’re in)

All of these actions—not always visible, but definitely happening—require active listening, which means I shouldn’t space out.[3. When I’m working, I shouldn’t space out, but I have. The goal is zero instances of spacing out. Still working on it.] I need to be present and focused. We all know when someone isn’t paying attention to us.

When I do speak, I try to ensure that every sentence serves a purpose.[4. When I’m feeling more ambitious, I try to ensure that every word I say serves a purpose. Sometimes that makes me sound pedantic or brisk, which often makes people feel uncomfortable. I learned early on that most people feel more comfortable with a psychiatrist who is a human being, not a psychiatrist who could be a robot.] Sometimes I ask questions when I want to make a statement; sometimes I say nothing, even though the individual may want me to fill the space with something (reassurance? confirmation of inaccurate ideas? answers that no one has?). I’m frequently generating hypotheses and testing them (is this person experiencing paranoia, or would he say more to another colleague? if this person intoxicated, or is there a medical issue present? does she actually want to die, or is she feeling powerless in the face of adversity?), while trying to show empathy and kindness.[5. Kindness is often associated with warmth. However, people can demonstrate extraordinary kindness without warmth. Consider people who put themselves in danger to protect others. Warmth is often absent there, but kindness overflows.] I don’t want to come across as an automated flow chart.

All of that—and more!—is happening when I’m doing clinical work. That takes a lot of energy. If I don’t have to use that energy, I won’t.

2. I don’t know how to “analyze” people. Upon hearing the word “psychiatry”, some people conjure up images of New Yorker cartoons with couches and stodgy psychiatrists sitting behind them. Psychiatrists and other mental health professionals usually go through extra training to learn psychoanalysis. The tradition of “analysis” goes back to Freud and, well, I’m not a fan.

Now, to be clear, there are some ideas that stem from psychoanalysis that I think have some value (for example, Malan’s text on psychodynamics offers interesting and, at times, useful perspectives on symptoms and behaviors). However, I don’t think everything boils down to love and work. Or sex and violence. I don’t think women are envious of men because men have penises. I think we all probably have an “unconscious” or “subconscious”, but I can’t prove it. I also don’t think the unconscious/subconscious is simply an arena where good and evil, depravity and virtue, and other polarities are constantly duking it out.

My disdain of psychoanalysis stems, in part, from cultural reasons. Freud and his buddies came from Western Europe (particularly Austria and Switzerland). America is a product of Western European ideas, and while I was born and raised in the US, I was raised by people who were not. I was inculcated with Confucian, Buddhist, and Taoist ideas. The psychologies of these traditions don’t refer to constructs like ids, egos, and superegos. They instead focus on filial piety, the importance of community over the individual, harmony as a paramount virtue, and the reality of suffering. These manifest more between, rather than within, individuals.

3. I’m not my job. Yes, I have been fortunate enough to go through medical and psychiatric training and do the work that I do, but that’s just one aspect of who I am. In my youth, psychiatry was not a part of my identity. If I am lucky enough to live long enough to retire, psychiatry will be something of my past. This is just a long phase of my life.

So, rest assured, I won’t analyze you. If I ask you questions, maybe I just want to get to know you.