Author: Maria Yang, MD

Categories
Consult-Liaison Education Medicine

Thoughts about the Digital Pill.

Reader and stellar nurse Natalie[1. I know Natalie is a “stellar” nurse because we used to work together.] wondered about my thoughts about the digital pill.

My initial reactions were similar to several of those who were interviewed for the article. The digital pill, which provides electronic information to confirm whether someone has ingested the medication, has great potential to become a tool of coercion. Aripiprazole (Abilify) is classified as an antipsychotic medication, which is often prescribed to people who have beliefs that machines and other surveillance tools are in their bodies. Why would the nascent technology of a digital pill make its debut for this population?

I have several other concerns about this digital pill:

(1) The purported mechanism of action for aripiprazole (Abilify) involves hand-waving, which is yet another reason why its debut as a digital pill is perplexing. To the manufacturer’s credit, the package insert for arpiprazole is blunt: “The mechanism of action of aripiprazole in schizophrenia or bipolar mania, is unknown.” (Section 12.1.) The explanation in the scientific papers, though, gets those hands waving all over the place (warning: technical language fast approaching):

The development of D2 partial agonists is a logical strategy for the treatment of schizophrenia because the pathophysiologic mechanism of schizophrenia is thought to be based on too much dopamine activity in some regions of the brain and too little dopamine activity in other regions. A D2 partial agonist can act as a functional antagonist in areas of high levels of dopamine, such as the mesolimbic pathway, but not in areas of normal dopamine levels, such as the nigrostriatal and tuberoinfundibular pathways. Thus, a D2 partial agonist is expected to reduce the positive symptoms of schizophrenia without producing movement disorders or elevated prolactin levels. In regions of low dopamine concentration, such as the mesocortical pathway, a D2 partial agonist will show functional agonist activity.

Put into plain language, what all that means is aripiprazole might stimulate specific receptors in one part of the brain, but block those same receptors in other parts of the brain. The concentration of dopamine might determine whether aripiprazole stimulates or blocks those receptors.

I’m skeptical.

That’s like an antibiotic that only kills one specific type of bacteria in one part of the body, but doesn’t kill that same specific bacteria in other parts of the body.

How does that work? Especially since science has yet to determine the underlying causes of psychotic disorders, such as schizophrenia?

So, in sum, this is a digital form of a medication that has an uncertain mechanism of action for a disease that we don’t fully understand.

What?

(2) The focus on adherence to medication assumes that the ingestion of medications is the most important aspect of treatment. This may be true for some individuals, but does not apply to everyone. Psychiatry focuses on maximizing function and quality of life. Sometimes people can attain both without taking digital pills daily.

(3) Most people under my care don’t have access to technology like smart phones. Some of these individuals also have the most severe symptoms and are the most likely to benefit from a variety of interventions: Skills coaching, housing, nutrition, exercise, art, and talk and behavioral therapies, in addition to medication.

(4) I don’t know how the data from this digital pill will actually change care. Psychiatry, for now, still relies on the observation of thoughts, emotions, and behaviors of people. Whether someone is taking their medications or not may not actually change treatment plans.

For example, say Natalie is under my care and takes a digital pill. I learn that Natalie takes this medication five days out of seven. All sources report that she’s doing okay: She’s getting along with her family, is going to school or work, is keeping up with her rent, and continues to follow the blogs she likes. Do I encourage her to take the medication every day? What more gains might she make? What if it detracts from her quality of life to have to take a medication every day, particularly when she’s doing okay?

Or, what if the digital pill tells me that Natalie hasn’t taken medications at all since I prescribed them to her? And Natalie continues to experience significant symptoms? I guess it’s helpful to have confirmation that Natalie isn’t taking medication, but, if I have sufficient rapport with Natalie, she’ll straight up tell me that she’s not taking it. Why use a digital pill when I can get the information from someone directly? Particularly when she can tell me the specific reasons why she doesn’t want to take it?

Or, what if the digital pill tells me that Natalie is taking the medication everyday, but she also continues to demonstrate significant symptoms? Again, the confirmation that she’s taking her medications could be helpful, but if I have rapport with her and she continues to suffer from symptoms, it’s likely that she would tell me this information, anyway.

If physicians want people to trust them, then physicians must show that they trust the people under their care. There are easier and more compassionate ways to get accurate information without resorting to a digital pill.

(5) Lastly, who are we actually treating with this digital pill? Who is going to feel better with the data the pill generates?

This data won’t tell individuals anything they don’t already know. They will know if they took their medications or not. (And savvy patients will figure out a way to subvert this digital pill reporting: Maybe they will give the meds to a pet or to another person.) This data is meant to help physicians feel better, not patients.

If the goals of psychiatry are to help reduce suffering, improve function, and help people live the lives they want to lead, we cannot rely on medications alone to achieve this, particularly for those individuals with significant symptoms. Even if the data shows that someone is taking medications daily, that process measure is meaningless if the person’s overall function and quality of life remains poor.

Categories
Nonfiction Observations Reflection

Patients in a Resuscitation Room.

I didn’t post anything here last week because my dad, while walking, was hit by a car. (He is feeling better, thank you.)

When I arrived, my father occupied one of four beds in a resuscitation room. The other three beds were empty. It was still early in the morning and there were few people in the emergency department.

As the day wore on, other patients were wheeled into and out of the room. A pale yellow curtain with a floral motif enclosed the space around each patient. The patients and their visitors caught glimpses of each other whenever the ED staff pulled the curtains open.

While curtains provide visual privacy, they are not soundproof.

An inmate from the local jail came in with chest pain. He shared his entire medical history with his accompanying jail officer. After listening to the inmate’s monologue for about five minutes, the officer interjected, “I’m going to watch this TV show now.” The inmate, along with the rest of us, listened to what sounded like an action movie. The inmate sounded more disappointed than relieved when he learned that he did not need to stay in the hospital. He went back to jail.

A mother and father came in for reasons I never learned. Their young toddler with enormous eyes grasped the pale yellow curtain in her tiny fists as she explored both sides of the boundary. Their infant stopped wailing when the mother sang, her voice full and calm. When the family left, they took the laughter with them.

A woman with dark pink hair was wheeled in. Another car hit her while she was driving. Her voice was light and melodic as she expressed profuse thanks to the medics. Her voice cracked as she spoke to a friend on the phone: Was she ever going to get a break? Why did her friend hit her with the car? Why was this the third time in her life she was in a car crash? What if she never got sensation back in her leg? Why did she have so much bad luck? After she hung up the phone, she wept. She took her frustration out on the nurse. No one was at her bedside.

A slender man was wheeled in. He, too, was in a car crash. His answers to questions were short and quiet. The sadness on his face could have been new, though the wrinkles around his lips and eyes hinted that maybe he wore a sad face most days. He stared up at the ceiling. No one visited him.

My mother came into the room, too. My father recalled when he was last in an emergency department: His wife was short of breath and feeling exhausted. He remembered the week she spent in the hospital, all the questions, poking, and testing she had to endure, and how much she hated it.

“Now I understand why she didn’t like the hospital,” he murmured. The edge of the pale yellow curtain shifted, though no one was there.

Categories
Consult-Liaison Observations

Status Game Strategy.

How do you introduce yourself when you greet people, particularly those you don’t know?

Yes, your answer might depend on who you’re meeting. But what’s your general approach?

I try to emanate warmth: I make eye contact and smile. I do what I think will make the person feel comfortable. I listen and try to speak less than the other person… unless it becomes clear that the other person wants to listen more and speak less, too.

This strategy has worked for me: It helps me form and maintain relationships. This approach has produced few, if any, negative consequences.

Some people use a different strategy when they interact with others: They assert their superiority. They say things like they have “one of the great memories of all time” and “I went to an Ivy League college… I’m a very intelligent person.”

The other way to assert superiority is to denigrate others, such as commenting that others are “weak”, “lightweight”, and “fake”.

This, of course, is a status game. Who has higher status? Who should have higher status? And if I should always have higher status, how can I make sure that everyone around me recognizes that?

Sometimes people use this status game strategy because it’s the only way they know how to interact with other people.

Maybe they learned long ago that the people in their life only paid attention to them when they said something that asserted their high status. People only took interest in them when they said things like, “I’m a very rich person.” The attention of others makes them feel worthy, seen, and valued. It’s nice to have a lot of money, but some people crave a wealth of attention.

Asserting high status, though, becomes a vicious, reinforcing cycle. After a while, people won’t care when they hear things like “I’m a very rich person”. They’ve heard that before and won’t react the way they once did. So it escalates: Soon, these individuals have the best memory, the highest IQ, and the best words.

Even though these statements are false—and verifiably false!—it doesn’t matter. Remember that outrage and indignation are still forms of attention. And some people are never satisfied with the amount of attention they receive.

This status game strategy works for some people: It helps them form and maintain relationships. For whatever reason, it has produced few, if any, negative consequences.

There are other ways, of course, to interact with people. However, it takes time and practice to do something different. Why change what you’re doing if it’s worked for you for so many years?

People who behave this way don’t need our pity. Pity doesn’t help anyone. One wonders, though, what happened to them in the past. Despite being over 70 years of age, they still don’t know how to interact with people without elevating themselves or putting others down.

Categories
Education Homelessness Medicine Nonfiction Policy Systems

People Get Better.

“What?!” he exclaimed. “Are you serious?”

“Yeah,” I replied, puzzled.

“That’s… amazing.”

“Yeah, it is.” I paused, finally realizing that he had never heard me talk about this before. “It actually happens a lot. People get better. People get better all the time.”

When I first met him, he screamed at me, his face red, spittle flying from his lips. He refused to believe I was a physician.

“Women can’t be doctors! They can’t!”

He did believe, though, that televisions could control his thoughts.

“They know what I think! When they start talking, they control what I think and what I say and what I do!”

He drew a swastika that covered the entire wall of his jail cell.

“Yes, I believe in white supremacy! But I’m not part of a group!”

He accepted medications on his own. First, the yelling stopped. Then, the swastika disappeared. Drawings of cute farm animals took its place. Within a few weeks, he greeted me with a smile.

“Hi, Dr. Yang. How are you doing today? I hope you’re well.”

He invited me to sit at the small table next to the kitchenette in his apartment.

“You want anything to drink?”

“No, thank you. How are you doing?”

“I’m okay. What do you know about the Mediterranean diet? I want to try that. I want to lose some of this weight.”

After discussing the merits of vegetables and lean proteins as they related to heart health, he leaned back in his chair. He then blurted, “It’s been six months since I smoked a cigarette.”

He never smiled when he shared his accomplishments. His condition prevented him from doing so. I smiled for him.

He resumed musing about dietary changes. I mused about how far he had come: Just 18 months ago he was living on the streets, often snarling at strangers and the voices that only he heard. He came to the attention of the police when he chased a young mother pushing her baby in a stroller. He threatened to beat them with the metal pipe in his hand. The police thankfully sent him to the hospital for care.

“Thanks for seeing me,” he said as he walked me to the door. The voices hadn’t completed disappeared, but he could ignore them now. “I like steak and potatoes, but I’ll try the leafy vegetables.”

He used both hands to smear his own feces on his arms, chest, and belly. He applied toothpaste to his elbows and his knees. I asked him why.

“because it’s protection it’s protection against all of you I shouldn’t be here I’m fine I’m not sick you don’t understand who I am they all know who I am you would be scared too if you knew who I am people know me from way back—”

He began howling at the door.

Within days of him receiving medications, all of that stopped. His jail cell was clean. He took showers. He never spoke of what happened. Neither did I.

I was taking a walk a few months later when I heard someone call, “Hey, Dr. Yang!”

I turned around and saw a group of men in uniform working. This man, suited up like his colleagues, waved at me and smiled.

I couldn’t help but smile—this is fanstastic!—but felt a twinge of embarrassment. Did he know that he had called me “doctor”? What would his coworkers think?

First do no harm. I waved back.

“Nice to see you, Doc,” he continued. “I’m doing good.”

“I’m glad to hear that. Take care of yourself.”

“I will, Doc. Thanks.”

People get better. The science hasn’t yet generated interventions that guarantee that everyone will get better. Furthermore, some people who could get better can’t access care due to barriers related to finances, policy, and other systemic factors.

Until then, we must share both stories and data (try this, this, and this) that people get better. It is amazing, but it shouldn’t be surprising.

Categories
Homelessness Lessons Nonfiction Observations Reflection

What Would It Be Like to Say Hello?

My first memory of encountering a person who appeared to have no place to live was during my first year of college at UCLA. A man was sitting outside a mini-mart, his legs crossed and his hair long. He looked tired and his clothes had stains on them. Feeling pity for him, I went into the mini-mart and purchased a turkey sandwich on wheat.

“Here,” I said as I handed him the sandwich. I beamed with Warm Fuzzies for Doing a Good Deed. “Take this.”

Because I expected him to thank me for My Act of Generosity, I was dumbfounded when he started yelling at me with contempt: “A sandwich? I don’t want that sandwich. I don’t like turkey and I have an allergy to gluten. If you really wanted to help me, you’d buy me a meal at an all-you-can-eat place. What am I going to do after I eat a sandwich? I’ll still be hungry. At least I can get another plate of food at an all-you-can-eat restaurant.”

“Okay,” I said, my cheeks burning with shame. He had a point: All hungry people prefer all-you-can-eat food to what now looked like a pathetic turkey sandwich. I took the rejected sandwich back to my dorm room.

My dining companion and I were seated at a long table that looked out a large window. Across the street was a man who we often saw in the downtown shopping district. He often carried a unrolled sleeping bag on his shoulder while talking and growling to himself. His clothes were soiled and too big for him. The soles of his shoes were falling apart. He didn’t have a beard, only uneven facial stubble. His eyes were light and his face was dark from smears, smudges, dirt, and dust.

“He doesn’t look well,” I said to my dining companion. The man was sitting on his rumpled sleeping bag on the sidewalk while engaged in an animated conversation… with no one. Sometimes he leaned back against the side of the building and puffed on a cigarette.

“I wonder when he last ate,” I wondered aloud.

“Why don’t you buy him something to eat?”

“Because he might not want that. Some people feel shame when people just give them food. They don’t like that other people think that they don’t have enough money to buy food for themselves. And I don’t even know what kind of food he wants. When we’re done eating, let’s go over there and ask him.”

As we approached him, his posture was relaxed and he was about halfway through his cigarette. His clumpy hair was falling into his eyes and everything he was wearing was soiled. He was engrossed in a conversation, occasionally making a point with his right hand.

“Excuse me?” I asked.

He continued talking.

“Excuse me?”

He stopped talking, turned his head, and looked at me. He remained still as the swirls of smoke from his cigarette defied gravity with ease.

“Hi. Do you want some food?”

Another tendril of smoke dissolved into the night before he answered: He shook his head no.

“Are you sure?”

He nodded yes.

I smiled and waved good-bye. I heard him resume his conversation as we walked away.

In retrospect, I should have introduced myself and asked him for his name. And I wonder if, next time, he will be hungry and accept an offer of food.

Sometimes we believe people are so different from us. How could there be anything similar between that guy talking to himself and sleeping on the street and me? What do I have in common with that guy wearing dirty clothes and carrying a sleeping bag around?

Well, we all share the wish to be treated with dignity. We want people to acknowledge us, our presence, our existence. We want people to see us as equals, not less than. We want people to show us respect, to see us as people who have worth.

Maybe you see someone in your daily commute who sleeps outside or doesn’t seem to have any money. Maybe it’s someone who sits against a wall with a sign asking for help.

What would it be like if you said hello that person? Or made eye contact with that person and smiled? What would it be like to acknowledge that person as a person? What’s gotten in the way of you doing that in the past? What is the worst thing that could happen if you tried that? What’s the likelihood that your worst fear in this situation would come true?

What would it be like if we said hello to everyone in our communities? Because aren’t these individuals who sleep outside and talk to themselves part of our communities?