Author: Maria Yang, MD

Categories
Lessons Medicine Nonfiction Reflection

On Gratitude.

Expressers significantly underestimated how surprised recipients would be about why expressers were grateful, overestimated how awkward recipients would feel, and underestimated how positive recipients would feel.” – Undervaluing Gratitude: Expressers Misunderstand the Consequences of Showing Appreciation

The past 30 days have been unusual because of the number of professional gestures of gratitude I’ve received:

  • I received a clinical faculty award from psychiatry residents for my teaching efforts.
  • An hospital administrator contacted me in my professional capacity; she later revealed that she was a former patient of mine and thanked me for our time together.
  • A former patient contacted me to let me know that she is about to start law school, something she did not think she could ever do. She attributed her change in perspective to our time together.

These gestures are deeply meaningful to me. At a time when arguments, conflict, and discord seem to dominate our collective consciousness, how refreshing it feels to receive thanks!

As I do not work in an academic medical center, I never expected to receive a teaching award. While I do some teaching for the residency, I have limited exposure to the trainees. That the residents even thought of my name for the ballot is meaningful. In my professional role, I have the privilege of teaching topics related to psychiatry to a variety of audiences—community members, attorneys, judges, case managers, nurses, social workers. Praise from students, though, is of greater value to me than praise from judges and others who have similar social status. As one of my more precocious medical students once commented, “I should know what a good teacher is, since I’m a medical student and many people teach me….” It makes me grateful for the teachers[1. I believe that literally everyone you encounter in life is a teacher. Sometimes you don’t want to learn what they have to teach you, but that doesn’t dilute the value of the lesson. And sometimes the best teachers in our lives aren’t identified as “teachers”.] in my life who have helped me develop my teaching skills.

Similarly, it is always a delight to receive thank you notes from past patients. Even though I often cannot remember the names of people who were under my care in the past, I recall how many of them taught me how to improve my skills in listening, using plain language, and applying interventions—medications or otherwise—to improve their health. I also recall the shame, fear, and suffering that they shared with me… and how, sometimes, I screwed up and gave them reasons to distrust me in the future. Sometimes I did better. Sometimes I think I did better when, in fact, I did not.

My boss (who is not a physician) recently gave me some feedback: “Maria, you’re hard to read. I usually can’t tell how you’re reacting to something.”

I laughed. “You’re not the first person to tell me that,” I said before continuing, “Like, when I was a fellow in New York, I had supervision with an attending (a physician) and, for whatever reason, I burst into tears because I was upset. To his credit, he didn’t freak out. He, a native New Yorker, sat with me and commented in that direct way that New Yorkers are known to do, ‘I had no idea you were so upset. You should know that you don’t show any signs that you’re upset.'”

After my mom died, I have put more effort in expressing my emotions. (To be fair, though, most of the expressing happens in words, not in my face.) Most of these expressions are of affection and gratitude. It sounds dramatic, though it is true: We never know when people will leave our lives, whether from death or other reasons. As noted in the opening citation, we might not think that what we say has much impact on others. However, expressions of affection and gratitude, at least, cause no harm and, at best, are emotional gifts that strengthen social bonds and foster harmony.

There is value in expressing displeasure, too. Sometimes people need to know that we’re upset, that we feel distress with current circumstances. Though it might make us uncomfortable, expressions of displeasure can ultimately strengthen social bonds and foster harmony. Sometimes we must travel the difficult path, even if it means that we will travel alone for a bit.

I am not old, but I am also not young. I am grateful to have the opportunity to work as a psychiatrist and to teach others the little that I do know. I am grateful that you, dear reader, have made it to the end of this post. Thank you.

Categories
Consult-Liaison Lessons Medicine Nonfiction Reflection

On Suicide.

I still feel a little anxiety whenever I ask someone about suicide.

I have no fear when asking The Question—“Have you been thinking about killing yourself?”—but sometimes I find that I’m not breathing while I await the answer.

What if this person says “yes”?

This anxiety persists even though it’s literally part of my job to ask this question. Despite having asked this question thousands of times, I still feel a twinge of unease whenever it is time to ask. I still feel nervous even though people have answered “yes” when I’ve asked The Question. I still wonder if my interventions will be effective despite knowing that I have helped people choose to live.

I still have to remind myself that it is a blessing if someone tells me, “Yes, I’ve been thinking about killing myself.” It means this person trusts me enough to share this information with me. It means this person has faith that I’m not going to freak out. It means that we can talk about death, what it means to this person, and why suicide seems like the best option. It means that there is hope that the conversation will lead to a discussion of other viable options.

It means that, in this moment, this person is willing to live.

During my training, I had several teachers who would offer gentle correction to people who said, “I feel suicidal.”

“‘Suicidal’ is a thought, not a feeling,” they would offer. “What are the emotions that are leading you to think about suicide?”

That snippet looks condescending and contrived on the screen. When said with skill, it steers the conversation to areas that can lead to change.

It is hard, if not impossible, to change emotions with willpower alone. Consider all the unseen things that can shift your emotions:

  • a fragrance that resurrects a memory from your youth
  • the sound of stranger’s voice that reminds you of another person
  • the feeling of the sun on your skin after a dark winter

Emotions are powerful. They can promote certain thoughts or drive certain behaviors. Sometimes emotions feel so overwhelming that, to cope, we have thoughts that death is the best option.

“Do you want to die? Or do you want to feel different?”

Whenever I learn that someone has died from suicide, I recall five specific people. Three of them tried to kill themselves while under my ongoing care:

  • one arrived in the clinic with long, bleeding lacerations on the both arms
  • one had spent hours on top of a tall structure, debating whether to jump off
  • one missed an appointment and I somehow knew that something had happened; this person used a friend’s gun and shot a bullet through the chest

Two of them did kill themselves:

  • one jumped off of a tall bridge
  • one took an intentional overdose of alcohol and methadone

There are people who I have worked with in acute settings—crisis centers, jail, emergency departments, medical and psychiatric hospitals—who tried to kill themselves, but never told me. There are people who have killed themselves after I met them, but I haven’t learned of their deaths.

I don’t think about the five people frequently, but they cross my mind from time to time. I hope the three are living lives they believe are worth living.

I say prayers for the two who are deceased, but the words of my prayers come from a language that has no shape or sound.

To prevent suicide, we must be willing and able to talk about it. This doesn’t mean that anxiety, fear, and discomfort are absent during conversations about death and dying. Talking about suicide does not increase the likelihood that people will kill themselves. In fact, these conversations often bring relief; it offers a perspective that frequently differs from the one that predominates in our heads.

The onus to broach this topic should not be solely on the person who is thinking about suicide. If we ever sense that people we love are not doing well, asking how they’re doing and learning more about what’s on their minds shows that we care.

When people are thinking about suicide, sometimes the best way we can help them is to let them know that we see them. We want them in our lives. And that may be how we can help them choose life.

Categories
Nonfiction Reflection

On Dignity.

There were about nine of us waiting to cross the street. Several were Asian; there were also a few black and brown men.

A van approached the curb to turn. It was one of those vans with a back door that slides along a track. That back door was wide open, even though the van was in motion. As it pulled closer, we saw that there were three young white men seated in the back. They were wearing shorts and sunglasses. Their legs were spread wide, occupying the space with confidence.

The young white man seated closest to the open door called at us as the van passed:

“… ching ching ching chong ting ting tong tong…”

The man of color next to me swiftly raised his arm and made a gesture with his hand. The young men in the van saw this gesture and shouted their musical slurs in a higher pitch in response.

“What? That still happens? Are you kidding?” she exclaimed.

“Well, yeah,” I said, perplexed. “The last time this happened to us was about three or four months ago.”

“But we’re in Seattle. And there are so many Asians here, on the West Coast. This really happened to you?”

These are probably the same people who see the color of your skin and say terrible things to you, I thought. Why are you surprised?

He and I had never met. He knew that I was conducting a clinical interview with someone else, but kept talking at me, anyway:

“… stupid f_cking whore, that’s what you are, you think you’re better just because you’re in a white coat, but you’re a f_cking whore, a c_nt, you should go finger f_ck yourself and die, you stupid f_cking whore…”

Sometimes, I can’t help but laugh with amusement at the racism and sexism lobbed at me. Like that one time I was eating an egg custard in Chinatown in New York City. I was leaning against a brick wall, enjoying an afternoon treat; Asians of all shapes, sizes, and ages walked past me. A non-Asian man saw me from across the street, stopped, and shouted, “CHINK!” before resuming his stroll.

… but… but… you know we’re in Chinatown, right…?

Other times, like this most recent instance of the open van, I feel more troubled. I wasn’t fearful for my safety when the van sped past, though I was aware how things could escalate. I wasn’t going to stop doing my work when the man insisted I am a “f_cking whore”, though I wondered if others agreed with him, but just kept silent.

It’s toxic and it’s tiring.

People want and deserve a basic level of dignity. It doesn’t cost anything to be civil, to be humane. Why some people sacrifice humanity and civility to assert higher status, I don’t know.

Would these young men in the van have sang their racial slurs at me if they knew I spoke perfect American English? What if they learned I am trained as a physician? What if they learned I work in a jail and helped out someone they knew? What if they found out I like the same cookies they do?

Would the man who insisted that I am a “f_cking whore” have cared if I was able to help address his health concerns? What if I interacted with him in a way that was better than his past experiences with people in white coats? What if he and I shared the same concerns about the rising rents and gentrification in Seattle?

When groups of people—complex, complicated, multifaceted humans with thoughts, hopes, talents, and dreams—are reduced to a single trait, it’s easy to denigrate and dismiss them.

When our nation has an elected leader who reduces groups of people to a single trait—“rapists”, “[they] all have AIDS”, “grab them by the pussy”—then other ignoble acts don’t seem so bad. To be clear, indecency and baseness obviously existed before the current President. The expectation for public discourse, though, is now at a different set point.

Is it really that bad when someone repeatedly says “Konnichiwa!” to you in a sing-songy voice, even after you tell that person that you’re not Japanese? I mean, it’s not like that person was trying to ban all people of the Islamic faith from entering the United States.

Is it really that bad when someone says, “Wow, you speak English really well!” upon meeting you? That seems like nothing when the President got on stage and mocked a citizen with a congenital condition.

A close friend of mine provided counsel to me many years ago when I expressed distress to him about a personal issue.

“You don’t have to work on this problem every single day,” he said. “It’s a complicated problem that does not have an easy solution. It’s okay to take a break. It’s not like anyone can solve this problem quickly.”

When we grow weary from complicated problems like racism, sexism, incivility, and dehumanization, we must remember that it is okay to take a break. Not an indefinite break, but a break. It’s not going to make an enormous difference if you take a week off from fighting racism; that’s been going on for centuries. Stepping away from your efforts to stop dehumanization for a little bit doesn’t mean you’re weak; it just means you can rest and recuperate so you can sustain this work for the upcoming years.

Things often don’t change as fast as we want them to, but that doesn’t mean that they won’t change. We must maintain our own abilities and willingness to show humanity, civility, and kindness to ourselves and others. Only when we do that can we hope and work to ensure that everyone experiences dignity.

Categories
Medicine Observations Systems

Representation Matters.

This post comes directly from a Twitter conversation I was in a few days ago:

Screen Shot 2018-04-22 at 1.28.25 PM

… though this topic has actually been on my mind for nearly a year due to some events that have occurred at work.

Many medications that were originally developed for the treatment of schizophrenia, called antipsychotic medications, are now used for other conditions, such as major depression and bipolar disorder. (The reasons for this are beyond the scope of this post. However, I will comment that this is why the “serotonin theory” of depression should really be called the “serotonin hypothesis“.) Several antipsychotic medications come not only in pill form, but are also available in long-acting injectable forms. Instead of swallowing pills everyday, some people receive an injection of medication once every few weeks or once a month. These medications are injected into shoulder or butt muscle.

Some people prefer to receive injections because that means that they don’t to remember to take pills everyday. Many people who accept long-acting injectable medications do well. No one would guess that they have had experiences hearing voices or believing fixed, false ideas. Some of these individuals report that these medications have saved their lives.

Some people, in varying degrees, are coerced into receiving injections (e.g., payee allowances—money—are handed over only after the individual receives the injectable medication; courts “encourage” individuals to receive injectable medication). Long-acting injectable medications are never used in emergencies, regardless of who is defining the word “emergency”.

Most people prefer not to get shots of medication, even if they know they are in their best interests. Many adults look away and wince when they receive vaccines, even though they know that the benefits far outweigh the risks. Most vaccines, though, are available only in injection form, so people don’t have a choice as to how else they can receive the vaccine.

So, with that, let’s look at the advertisements for long-acting injectable antipsychotic medications and any intersections they have with race. The target population is admittedly small: Only around 1% of the population has a diagnosis of schizophrenia at any given time. (However, if you’re part of that 1%, this stuff matters a lot.)

Here’s the landing page for one long-acting injectable antipsychotic medication:

InvegaSust

We see what look to be white people with sporting equipment. I’ve drawn in a pink arrow to show the link that leads to the page about the use of this medication for the treatment of SCHIZOPHRENIA. If you click on that link, it brings you here:

InvegaSchizophrenia

Anything different about the people in the photo?

There are journal articles that span decades that show that schizophrenia is overdiagnosed in black people. One wonders: Do the ads come from the overdiagnosis? Or does the overdiagnosis come from the ads?

To be fair, if you scroll through the photos in that image, the other photos are of white people, including women. However, the scrolling does not automatically occur. The photo of the three men of color is what you see when you click on “schizophrenia” from the main page.

So what happens if you click on “schizoaffective disorder” from the page for schizophrenia? (Curious that there isn’t a link to schizoaffective disorder on the main page.) This shows up:

InvegaSchizoaffective

Only women for a psychotic disorder that also features mood symptoms, huh? (Side note: There’s ongoing debate within psychiatry whether schizoaffective disorder is even a valid condition. Meaning, psychiatric researchers are still arguing about whether this condition even exists. This is a topic for another post.)

“Oh, Maria,” you might be thinking. “You’re reading too much into this. It’s just one ad for one medication.”

Okay, let’s look at another long-acting injectable antipsychotic medication. How about this landing page?

AbilifyMaintena

Note the comment in the bottom right-hand corner: “Model portrayals.” Meaning, the company chose these specific images for these specific diagnoses.

The “schizophrenia” link takes you to a page that has scrollable photos: Two women with less melanin and a man with more melanin. The “bipolar” link has two scrollable photos: One light-skinned woman and a darker-skinned man. Maybe there’s something there; maybe there’s not.

Here’s another one for essentially the same medication, but with a different manufacturer:

Aristada

Okay, so this photo assortment seems to strike a more even racial balance. I won’t nitpick further on this one.

Let’s go to the longest-acting injectable antipsychotic medication on the market right now, an injection that is administered once every three months:

Trinza

Oh goodness.

If you click through the “Go to videos” link, there are three video vignettes. Two of the individuals are black. Again, one wonders: Do the ads come from the clinical diagnosis? Or does the overdiagnosis come from the ads?

The other long-acting injectable antipsychotic medications are now available as generic formulations, so their websites are full of text. My efforts to find past advertisements, commercials, and press kits for them yielded no images. I find that interesting, too.

To be clear, these ads comprise a small sample and are for a specific form of medication. I don’t know what advertisements look like for all other psychiatric medications. Maybe I am reading too much into these websites. However, when (1) local, regional, and national data indicate that people of color, particularly African Americans, are more likely to receive a diagnosis of schizophrenia, (2) medications used to treat schizophrenia often have significant side effects of sedation and lethargy, and (3) these medications are available in long-acting forms, it makes me wonder.

Categories
Education Medicine Nonfiction Reflection Systems

I Have No Plan.

We learn about SOAP notes early in medical school:

S = Subjective, or what the person reports to you

O = Objective, or the data you gather from the person (vital signs, physical exam, lab studies, etc.)[1. We’ll put aside for now the discussion of the problems with labelling these sections “Subjective” and “Objective”.]

A = Assessment (a diagnosis and formulation based on the Subjective and Objective data)[2. We’ll also put aside for now the potential problems that arise at the intersection of billing and diagnosis.]

P = Plan (the next steps or recommendations that occur as a result of the Assessment)

Most medical notes, regardless of specialty, setting, or length, follow this SOAP format.

While recently typing up some notes, I blurted to my colleague, “What I really want to write under the ‘Plan’ section of my note is, ‘I have no plan’. Can I do that?”

Sometimes the Plan is direct and clear:

S: Mr. Doe reports that he hasn’t heard voices in three days. He finds it easier to read books. He denies side effects from medicine.

O: He isn’t talking to someone who isn’t there. He’s not demonstrating tremors. He’s showing more emotional expression in his face.

A: A psychotic disorder that could be due to This, That, or The Other Things.

P: No changes in medication. Continue to encourage activities he enjoys. Cheerlead his ongoing efforts to monitor his own progress. Follow up in a few weeks.

Sometimes I have a Plan, but it’s not a Plan I write down because the next steps or recommendations are beyond our control:

S: Ms. Doe reports that she uses methamphetamine to help her stay awake at night. She fears that if she falls asleep, men will hit or rape her. She still hears voices. They have gotten more intense since she left her foster family a year ago, as a member of the foster family was molesting her.

O: She’s distracted, looks exhausted, and, since she doesn’t have a safe place to stay, has little interest in reducing or stopping her use of methamphetamine.

A: Methamphetamine use disorder. Some flavor of a trauma- or stressor-related disorder. Maybe an anxiety disorder? Maybe a psychotic disorder that could be due to This, That, or The Other Things?

P: (1) Ensure that people have safe places to live. (2) Stop human beings from sexually assaulting other human beings. (3) Instill proper ethics and morals into all of humanity.

Then, there are times when the Plan doesn’t include concrete steps that will guarantee forward movement:

S: Mr. Doe was reluctant to talk to me. He only shared that his words are potent and, if he misspeaks, my face will melt off. He said that he doesn’t want to hurt me or anyone else with his power. My efforts to inform him that my face will remain intact were unsuccessful.

O: He’s eating, he’s sleeping, he avoids other people, and this is the most he’s spoken to anyone.

A: Probably a psychotic disorder due to This, That, or The Other Things?

P: ???

Since I have to write something, the Plan in these situations usually looks like this:

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P: Continue to build rapport as tolerated. Gather more history. Will try to talk to him again in X amount of time.

The most difficult notes to write are those when I know I have no plan. This is distinctly different from not knowing what the Plan should be. (This is a function of time and experience, of knowing what I don’t know.) These situations usually involve a combination of the last two situations I described:

S: Ms. Doe said that there is a dead baby inside of her. Records state that she has reported this for the past four years, though there is no evidence that she has been or is pregnant. She was the victim of a significant assault five years ago; she sustained head trauma from this event, which many believe is the cause of her erroneous belief. She visits emergency departments multiple times a week due to her belief that there is a dead baby inside of her. She has assaulted both of her parents multiple times, so they have filed “no contact” orders against her. Because she now has no place to live and her anxiety about a dead baby inside of her persists, her behaviors sometimes result in law enforcement encounters, which land her in jail. She has avoided psychiatric services because she insists that her belief is true.

O: When she does talk, she speaks with dread and grief about a dead baby inside of her. Other times, she screams, demanding that people leave her alone. When she menstruates, she smears the blood all over herself while crying, mourning the loss of what she believes is her dead baby.

A: A psychotic disorder probably due to the head injury, but maybe due to Other Things?

P: … [I have no plan. I just don’t.]

The best Plans are those constructed with the person in question. Unfortunately, Ms. Doe usually doesn’t have a plan, either. So, I write down the little I can actually do:

P: Work with team to build rapport as tolerated. Find out what else she cares about. Work with other systems to create a plan to help reduce her distress without causing more trauma.

… and hope that patience and persistence will reward us in the future. Because sometimes hope seems to be the only thing we can do.