Author: Maria Yang, MD

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.

Categories
Education Informal-curriculum Medicine Reflection

Some Thank Yous.

To the intern on the trauma surgery service when I was a medical student: Thanks for occasionally wearing leather pants to work. Thanks for smiling and having a sense of humor despite having to round on thirty patients. Thanks for teaching us medical students while running a significant sleep deficit.

To the internal medicine resident who wanted to become a cardiologist: Thank you for indulging me and telling me how you dealt with the stress of medical training: You became still and tried to hear your heartbeat. When everything else seemed out of control, you focused on the steady rhythm emanating from your chest. That’s still something I do from time to time.

To the family practice physician who worked in the suburbs: I still don’t understand why you thought it was okay to pour liquid nitrogen on my head in front of the patient after you frosted the warts off of her feet. I mean, I do understand—you had power! I had none! what an amusement for you!—and thank you for showing me what a professional should never do.

To the surgical tech who was shaving the pubic hair off of a woman who was already under anesthesia: I don’t know why you and I were the only ones in the operating room. You knew I was there. As you were shaving her groin, you said, “You’re a fat bitch. You are such an ugly, fat bitch. I hate that I have to shave your fat ass.” She may not have heard you, but I did. As a medical student, I was too scared to tell you to stop. Thank you for showing me your cowardice and cruelty, as there are, unfortunately, others like you in medicine. I have since learned to speak up when people say violent things.

To two of my fellow interns: You stand out in my memory from that year. (One now works as a senior medical officer for a public health district in New Zealand; the other works in emergency medicine in an academic medical center in Texas.) We were brand new doctors running around the hospital and had no idea what we were doing. Do first, think later! I admired both of you for your intelligence and am grateful that we worked well together. I remember how you offered to help me when I was buried with neverending work. What I remember most, though, is how you made me laugh. When things were terrible—when the disease, dying, and death was crushing—you helped me smile when there was nothing else we could do.

To one of my medical students when I was an intern: Thank you for taking the time to write a letter to my residency director to express praise for my teaching abilities. You were both precocious and earnest: “I should know what a good teacher is, since I’m a medical student and many people teach me….” I hope you continue to write letters to those teachers who helped you grow.

To the male psychiatrist who took me to see a patient in a post-surgical setting: Thank you for teaching me who benefits from the questions we ask. We had just met her; she was weeping and told us she was uncomfortable. Out of nowhere you asked her if she experienced sexual abuse as a child. She answered yes. You then ended the interview and, while we were walking away, said to me, “I knew from her behavior that she was sexually abused as a kid.” I learned that I should never ask people questions just to show off.

To a female VA attending psychiatrist: Thank you for your enthusiasm for Cole Haan shoes. You were always so well-groomed—I imagine you still are—and your delight for shoes showed me that even sharp, warm attending physicians get excited when expensive shoes go on sale. You showed me that you weren’t just a doctor; you were also a person.

To the pharmacist who said little, but brimmed with wisdom when he did speak: I wish you were still alive. I think of you often: sometimes when I’m flummoxed over someone’s medication regimen, more often when I’m not sure how to best connect with the person in my care. You are the only person who has ever compared me to a bottle gourd: “Circumstances and people might try to bring and keep you down, but you’re like a bottle gourd in water: You pop right back up again.” After you died, I bought a bottle gourd to remind me of your high praise.

To the male psychiatrist who paid too much attention to me: Everything about that situation still makes me sad, but it helped me grow as a person and as a professional. I now tell trainees—particularly the women—that they must speak up, that they aren’t alone, that they don’t have to put up with bad behavior.

To the psychiatrist who worked as a commissioner for mental health: I wish you were still alive, too. I also think of you often: When systems don’t work and seem designed to fail, when people focus more on how things look than on how they actually are, when money seems to matter more than people…. I wish I could ask you what I should do. You often advised me to continue to ask questions, especially when I wanted to “do” something. I still heed your advice: If it scares you, then you should probably do it. Sometimes it is scary to ask questions, too.

To a male VA attending psychiatrist: Thanks for your candor while I was crying. “I had no idea that you were that upset,” you said. “You should know that you don’t show how you’re feeling. People probably have no idea.” You weren’t the first (nor last) person to recognize that I often don’t show how I’m feeling, but you were the first supervisor to tell me this to my face. You weren’t warm in that moment, but you were kind. And thanks for not freaking out when I started crying.

To my first boss: Thanks for saying explicitly that it’s okay to be mad. As an unintended corollary to the feedback I got from the male VA attending psychiatrist, you told me that it’s okay for people to know that I’m angry. “It shows people that you care. And sometimes people need to know that.”

To all the people who have allowed me to be your doctor: Thank you for your patience. The longer I practice, the more I realize how little I know. Thank you for your grace when I ask you intrusive questions. Thank you for your calling me out when I mess up. Thank you for giving me the opportunity to try to help you. Thank you for thanking me when you are better and don’t need to see me anymore. Thank you for teaching me new things and reminding me of things I still need to work on.

Categories
Medicine Nonfiction Observations Reflection Systems

What Doctors Look Like.

I don’t remember her name, but I do remember her light brown hair, the simple nose ring that looped out of her left nostril, and the calm and centered presence she had with patients. She came across as unassuming, professional, and caring. We were both in medical school, though she was two years behind me. I admired how she treated people.

I don’t remember his name, but I do remember that he worked as a nephrologist (kidney specialist). He had a slight paunch and frequently wore dress shirts with short sleeves. The knots of his neckties were always loose. Students regarded him as an excellent teacher who revealed the mysteries of the kidney with tireless enthusiasm.

The nephrologist and I, among others, taught a course for junior medical students. Someone praised the bedside manner of this calm and centered medical student. The nephrologist interjected, “That might be true, but she doesn’t look professional. It’s the nose ring. Physicians shouldn’t have nose rings.”

I didn’t say anything in response. He was still an attending physician and I was just a medical student. His comment struck me: Did it really matter what doctors look like?

I have thought about that snippet over the years. Did he ever give her that feedback ? If he did, how did she take it? Did anyone else find his remark curious? Did any of the other attending physicians disagree with him? If they did, why didn’t they speak up?

After I became an attending physician and navigated ongoing perceptions of what I “should” look like, more questions have come to mind:

What if the medical student was a white male and had a nose ring? Would the nephrologist have made that comment? (Probably?)

What if the medical student was a stellar student and demonstrated clinical excellence? (My impression is that she did well in her coursework and that the comment about her nose ring was in the vein of, “If only she didn’t have the nose ring….”)

What if the medical student wore the nose ring for cultural reasons? Would that have mattered to the nephrologist?

What if the nephrologist learned that certain populations of patients were more likely to trust her than with him because of the nose ring?

What did the nephrologist think doctors should look like? (Clearly, he did not think they should wear nose rings.) How did he learn what doctors should look like? Who determined the definition of “professional” in the world of medicine?

Did it really matter what doctors look like? To medical students, of course it did. When we started our clinical rotations, we saw the attire of resident and attending physicians: Think Banana Republic or J. Crew, with the requisite long white coat on top. So what did we all do? We started shopping for “professional clothes”, except few of us had the money to buy stuff from Banana Republic or J. Crew. We cobbled together outfits from shops we could afford.

The pressure to conform, however, went beyond what we wore. There was only one female trauma surgeon who worked with medical students and, while students spoke well of her, resident physicians sometimes remarked that she was “too emotional”. During operations, male surgery fellows told female medical students, “You should feel this lung now, since you’re probably going to go into pediatrics or family practice.” Many of the attending physicians were heterosexual white males. Those of us who were not—men of color, women with or without nose rings, those who identified as LGBTQ—navigated how to conform to the values and behaviors of heterosexual white males, such as the nephrologist. Though some of these values and behaviors have no clinical relevance (e.g., wearing a nose ring does not affect how a physician washes her hands, gathers a history, or conducts a physical exam), they do affect how one goes through medical training. If enough attending physicians make comments about the nose ring, you might stop wearing it, even though the nose ring is something you value as a person.

What do you do, though, when the issue isn’t a nose ring, but your skin color? sex? accent? sexual orientation? culture?

When surveying the community, many people comment that they feel more comfortable working with health care professionals who look like and share the same experiences as them. Many women, for example, prefer to work with female gynecologists. People who speak languages other than English often feel more comfortable working with physicians who also speak the same language. Americans who are not white often comment that it is often easier to talk with non-white physicians about health concerns.

People with tattoos and nose rings may find it easier to talk with a physician with a nose ring. If the goal is to help keep people healthy and living the lives they want to lead, is it fair to say that nose rings are unprofessional? If the physician with a nose ring is able to connect with her patients and thus serves her community, should we indoctrinate her with the idea that nose rings are unprofessional?

Out of habit I still wear slacks and dress shirts when I see patients. I was trained that I should dress a certain way to both show respect to my patients and demonstrate that I am a professional.

The only time I did not routinely dress in slacks and dress shirts was during my time doing outreach to people who were sleeping outside. Part of this was due to function—it’s much easier to jump over puddles and slide past chainlink fences in jeans and a sweatshirt—but part of this was also because a doctorly outfit was often a liability in these settings.

How would you react if, while eating lunch outside, someone wearing a white coat and a stethoscope around her neck came up to you and asked, “Hi. How are you doing? Are you okay?”

Feedback I often received throughout my medical training (and continue to receive now) is that I do not speak up enough during rounds and related meetings.[1. Even though this post is over one thousand words, it’s true: I actually don’t talk much when working.] My seeming reticence partly reflects my introversion; it also reflects Chinese Confucian values. Medicine has trained me to talk more. I will never know if my taciturn tendencies have caused more problems for my patients (I hope not), though we all appreciate someone who is willing to listen.

And while I am sure that the nephrologist would have disapproved of unnatural hair colors, I can’t count the number of times vulnerable people with significant psychiatric symptoms were willing to talk to me simply because of my locks of curious color. This holds true even for people without any psychiatric symptoms.

I trust that the medical student who wore the nose ring has become a fantastic physician. I wonder if she still wears a nose ring. I hope she still does.

One way we recognize physicians is by their white coats. The rest of it—sex, skin color, accents, nose rings, tattoos, hair color, age, height, weight, etc.—shouldn’t matter.

Categories
Consult-Liaison Informal-curriculum Lessons Medicine

You Don’t Have to Like Everyone.

You don’t have to like everyone under your care. And you probably won’t, which is okay.

Own how you feel. If you insist on telling yourself that you should like someone when, in fact, you don’t, it will come out in other ways: The tone of your voice, the expressions on your face, the way you position your body.

There might completely understandable reasons why you don’t like the person under your care. Maybe he never seems to hear what you say. Maybe he doesn’t follow any of your recommendations, but he blames you for lack of healing. Maybe he expresses opinions you find offensive. Maybe he calls you racial slurs. Maybe he’s thrown things at you. Maybe he threatens to rape you. Maybe he’s told you that he will kill you and your family.

People do things like that for reasons that make complete sense to them. You may disagree with or misunderstand their reasons, but despite that, they are still people. Even though you may dislike some people under your care, you must still recognize that they are still human beings. The moment you refuse to recognize the humanity of the other person, you are at risk of inflicting violence upon them. Violence can manifest in many ways, including neglect.

First, do no harm.

It is possible to dislike someone and do no harm.

When we don’t like someone, it is much easier to assign blame entirely to the other person (e.g., “He’s an annoying @$$hole”). While it is possible that the problem has nothing to do with you and everything to do with the other person, that doesn’t change the fact that you cannot control other people. You can’t make someone less of an @$$hole. You, however, can make yourself view the situation in a different perspective.

Own how you feel. Let’s say he is, in fact, an @$$hole—something you cannot change. What if you focused instead on yourself?

“I really don’t like him. I feel dread whenever I have to see him.”

The reasons behind your dread make complete sense to you. When you acknowledge your dread and dislike to yourself, you give yourself more options as to how to proceed. You now have more control over the situation.

When you don’t like someone who is under your care and you acknowledge this, you can:

  • get support from your trusted colleagues. You can tell them how much you don’t want to see this person, how anxious and annoyed you feel about having to do this, and how much you don’t like this person. Get it out of your system ahead of time so you can be the professional you want to be when you actually see this person.
  • activate your internal coach. You can take some deep breaths and say a silent prayer before the interaction begins. You can rehearse some evacuation plans in case things start to run off the rails. Your internal coach can recruit your internal cheerleaders afterwards if the conversation goes well.
  • pause and remind yourself of your purpose. Your job does not include judging or shaming the person under your care. Your job isn’t to like the person under your care. Your job is to help the individual improve his health. Sometimes the people you care for have terrible life circumstances that contribute to the behaviors that you don’t like.
  • ask a colleague to see the individual so you don’t have to. Sometimes it is clear that the clinical relationship won’t work out at this time. We can’t be effective with 100% of the people we see (though we can try). Sometimes, the best way we can help the people under our care is to remove them from our care. (Sometimes, though, this isn’t an option.)

It’s often helpful to focus on the behaviors of an individual. When you focus on behaviors, you are more likely to remember and respect the person’s humanity. This keeps us professional and kind, even if we aren’t warm and smiling.

Indeed, he may do things that you don’t like… but he may also do things that you do like. And when we offer genuine thanks to people when they do things we like (e.g., “Thanks for your patience while I was asking you all of those personal questions,” “Thanks for summarizing your story quickly for me,” “Thanks for not calling me names today”[1. I have actually said, “Thanks for not calling me names today!” to people under my care and, no joke, the vast majority of them never address me with bigoted phrases ever again.]), people are almost always going to do those things more often.

You don’t have to like everyone under your care. Once you start owning how you feel, though, you might find that, most of the time, you do.