Author: Maria Yang, MD

Categories
Homelessness Nonfiction Policy Systems

How to Prevent All of This?

Some of the people under my care in the jail right now are quite ill. (This statement is always true, but it seems that the intensity of illness is greater now than usual.) As a result, the perennial question seems more urgent now: Is there any way to prevent All of This?

For some of them, it seems that the answer is No. Some of them sought out psychiatric services, attended appointments regularly, and had good working relationships with their physicians and therapists. They shared their concerns with friends and family members; they sought out help when they started feeling overwhelmed. Despite these relationships and support, they allegedly did things that resulted in significant criminal charges. And now they’re in jail.

For some of them, the answer might be Yes. Maybe if they had more people they trusted in their lives; maybe if they had a better connection with the counselor or doctor they saw that one time; maybe if their friends and family had more time and resources to seek help with and for them.

Then again, for some of them, the answer might be No, but for frustrating and sad reasons. Maybe their friends and family did everything they could to help them, but they didn’t want their aid. Maybe they became so fearful for their safety that they withdrew from everyone and, in isolation, their symptoms became worse. Maybe they believe that they are fine; it is the rest of the world that is confused and ill. Maybe their only experience with psychiatrists was involuntary hospitalization: Who wants anything to do with a system that takes away your rights and forces you to accept medication?

Some of these people are so young. To be clear, it’s troubling whenever someone of any age ends up in jail solely because of psychiatric symptoms. But can you imagine being 18, 19, or 20 years of age and landing in jail in the midst of hearing incessant, taunting voices, believing disturbing things that simply aren’t real, and having no visitors because the few people who are in your life are scared of you?

It’s heartbreaking.

At least these individuals come to clinical attention. And many get better: They form relationships; they talk with my colleagues and me; they learn how to get along with others; they reflect on what has happened and how to avoid similar consequences in the future; some take medication to help reduce their symptoms.

But then I think about all the people who never encounter law enforcement and never enter the criminal justice system, but they also experience significant symptoms. How do we prevent All of This for:

  • the man who doesn’t tell anyone any personal information and stuffs his tattered clothes with plastic bags to stay warm
  • the woman who won’t move indoors because she believes that the aliens will execute her if she does so
  • the woman who won’t leave her house because she believes her neighbors are cannibals
  • the man who sits all day on the sidewalk across the street from his old employer because he believes that he will get his job back

What about them? How do we help those individuals when the system ignores those who cannot or will not play by the rules?

Many mornings I see the same woman standing near a bus stop. The bus stop is covered, but she never stands underneath the awning. She stands behind the bus stop, even when it’s raining.

You can smell her—a mixture of sweat, dirty socks, and yeast—from several feet away. Pedestrians move around her the way water swirls away from large rocks on the riverbed.

Two black garbage bags sit at her feet. They are full. Plastic zip-lock bags poke out of one of them.

She is a young woman of color. She wears a dark hoodie that is too large for her slender frame, but it’s not zipped up all the way. She’s not wearing anything underneath the hoodie, not even a bra. An unwashed skirt smeared with dirt covers her legs. Her mangled sandals reveal that she has not clipped her toenails in many months.

She talks to an unseen audience and everyone can hear what she says. Her voice is rich and though her sentences do not make sense, she speaks with dignity.

The other morning the rain wasn’t the usual mist that falls from Seattle skies. The droplets were full and heavy, a shower of dark water as the sky was filling with grey light.

No one was standing in the bus shelter. Her clothes were already damp.

“Excuse me?” I asked. She had raised an arm to make a point in her discussion.

She fell silent and blinked a few times.

“Do you want to move so you’re under the bus shelter? So you won’t get wet?”

She turned her head and looked away.

“I can help you move your stuff. It’s raining pretty hard right now.”

She dropped her arm and turned her head further.

“What’s your name? My name is Maria.”

She glanced at me, raised her arm back up, and resumed speaking: “All in all, we must to the left….”

I stood there for a moment, waiting for a sign. None came. I walked away.

Categories
Blogosphere Nonfiction

The “Best Of” 2017.

There are ten days left in 2017.

This is the third iteration of my blog. I started this one in November 2010. The first iteration of my blog started in November 2000. That means I’ve been writing online for 17 years (???), though I fled the internet for about two years.

In looking back over what I wrote in 2017, these are the posts from this past year that had the most visits:

Disappointment. “My cohort graduated from our psychiatry residency almost ten years ago. The level of frustration and disappointment we’ve all experienced within the past two years is striking.”

My Seattle Times Op-Ed about #MeToo in Medicine. “The senior psychiatry resident at the University of Washington School of Medicine warned me ahead of time. She laughed as she said, ‘He’s weird. You’ll get used to him.'”

Thoughts on the Movie “Get Out”. “If you have seen Get Out, this post ponders the role of psychiatry in the movie. (Full disclosure: I enjoyed and recommend the movie.)”

The most popular posts on my blog, though, aren’t from 2017! These are the posts that received the most visits overall:

DSM-5: Schizophrenia. This post is a brief discussion about how DSM 5 defines schizophrenia. (I wrote about other diagnoses, too, but don’t know why this diagnosis got the most attention. I have a particular interest in people experiencing psychotic disorders; perhaps that shows?)

Personality Disorders to Difficult Interactions (I). “To be clear, though, just because you have a difficult interaction with someone doesn’t mean that that person has a personality disorder. There are plenty of people without personality disorders who behave in unbecoming ways.”

Do People Choose to be Homeless? “I cannot speak for all people who have ever been homeless. However, I have several years of experience working with people who were homeless and refused housing again and again, as well as people who left their housing and returned to the streets.”

I remain grateful to people who choose to take the time to read my writing. Some of you have been reading since the early days of my first blog; for that, I feel humbled. Thank you.

May 2018 bring you all good health, many blessings, and contentment. See you in the new year.

Categories
Consult-Liaison Education Medicine Systems

The Social History.

From the notes I read, it seems that other medical specialties limit “social history” to whether or not someone uses tobacco, drinks alcohol, or uses drugs.

“Social history” is meant to get a sense of the context in which people live. Where do they live? Who do they live with? How did they come to live there? Where did they grow up? What sort of work do they do? How much school have they finished? What do they do for fun? What are the important relationships in their lives? etc.

I almost always start my clinical interviews with the social history. There are several reasons why I do this:

One, it’s a more neutral place to start. My hope is that it will help the person feel more comfortable talking to me. Most of these questions are easy to answer, since many of them overlap with social conversation: Where do you live? How long have you lived there? This is also an opportunity to communicate through non-verbal communication: The nodding, the eye contact, and all the other behaviors that show that I’m paying attention and worthy of trust. (“See, it’s not so bad to talk with a psychiatrist.”)

Two, it puts the information the person shares with me into context. If people don’t have a stable place to live, then they have good reason to feel anxious about their safety and exhausted from poor sleep. If someone lives with other people who are struggling with substance use or are often fighting, then this person may not be able to recruit them to help with the tasks of daily life. They may not even feel safe staying with them, but don’t have other choices. One can’t expect someone to take medication on a regular basis when they don’t have enough money to buy food.

Three, if people don’t want to talk to me for whatever reason, the way they stop the conversation is useful information. Sometimes people are paranoid for a variety of reasons—some based in reality, some not—and they shut down the interview. Sometimes people want to talk to me, but they’re exhausted and ask me to come back later. Sometimes people don’t like something about me: my hair (it’s noteworthy how some people respond to my hair), my ethnicity, my clothes, my sex, the way I talk. I can’t change most of those things, and how people respond to all that tells me (1) how I can better interact with them in the future and (2) what might be going on that is causing them to respond this way. And sometimes people don’t want to talk to me because I’m not conducting the interview in a skillful way: Maybe I’m coming across as cranky, uncaring, or judgy.

Four, and most importantly, I want the person to know that I view them as a human being. I wince whenever someone immediately launches into their mental health history: “Okay, I have a diagnosis of schizophrenia and I take Zyprexa and Cogentin….” This tells me that this person got the message over time that no one is interested in him as a person; people only want to know his diagnosis and medications. But people aren’t their diagnoses or their medication regimens. All people have hopes and dreams; they have things they want to do and people they want to be. While a summary statement might make the interview more efficient, it matters whether this person volunteers at the animal shelter every week because he loves dogs or whether he stays at home and watches TV all day. This information is valuable, regardless of his diagnosis.

It takes time to get a social history. Short appointments, though, are short-sighted. It’s much faster to generate diagnoses from labs and studies; it’s much faster to write prescriptions than to listen to patients. If physicians don’t get an accurate history, then physicians are more likely to generate wrong diagnoses. Wrong diagnoses, along with no information about the contexts in which people live, lead to wrong interventions. Did anyone then actually save any time?

Categories
Informal-curriculum Medicine Nonfiction Seattle

My Seattle Times Op-Ed about #MeToo in Medicine.

The Seattle Times published an op-ed I wrote! Their editorial staff provided the title, #MeToo in medicine: ‘Who would believe a trainee?’

I wonder: What if I had a different byline? Would the Seattle Times have published it if I worked as a nurse? medical student? medical assistant?

What if I worked as a janitor in a hospital? Or in housekeeping?

What if I waited tables? worked in retail? had a job that is “off the books”?

The last sentence in my op-ed is “I was fortunate, but not all women are.” I was fortunate in that I had support from supervisors and colleagues, and that the psychiatrist in question didn’t do anything worse.

I remain fortunate, though, in that I have the privilege to be able to share this story to a wider audience. I have access that other people lack. And those are the people we should consider about when we talk about “#MeToo”.

The senior psychiatry resident at the University of Washington School of Medicine warned me ahead of time. She laughed as she said, “He’s weird. You’ll get used to him.”

When I first met with him, the psychiatrist lazily spun in his chair, his left hand tucked into his pants, his thumb hanging out. After he told me his expectations as my supervisor, he patted my right thigh as he ended the meeting.

I spent one day a week training in his clinic. He often put his hand on my shoulder. If he sat near me, he extended his arm to pat my leg. When I sat far from him, he crowed compliments in front of patients and other staff: “Dr. Yang is one of the best residents who has ever worked with me!”

He began to send emails to me at all hours of the day and night. They stopped referring to clinical research and developments; now he wrote of art, history and music that he thought I would enjoy. Some of the timestamps on his emails were near 2 a.m.

“Do as I say, don’t do as I do,” he chided in his emails. “Good night.”

My discomfort increased over time, though I wondered if I was overreacting. After all, didn’t another resident tell me that he was weird? She didn’t seem distressed with his behavior. Maybe I was too sensitive.

I asked two other supervisors, both psychiatrists, for advice. The male psychiatrist was angry and swift in his response: “You have to tell your residency director. This isn’t right.”

The female psychiatrist wavered. “I don’t know,” she said after a long pause. “It’s up to you if you want to say something. It could turn into a ‘he said, she said’ issue.”

She had a point: Who would believe a trainee over a tenured professor? Would he retaliate? How would this affect the rest of my training?

I decided to talk with him first. My request seemed reasonable: “Could you please stop touching me and stop sending emails to me that are unrelated to clinical work? I feel uncomfortable when those things happen.” I rehearsed.

The next time I saw him, he greeted me with a pat on the shoulder. I felt my face flush as I stammered, “Could you please stop touching me? It makes me feel uncomfortable.”

He paused, then smiled. “Why didn’t you tell me sooner? It’s not that big of a deal. I’m just being friendly.”

It was a big deal: He stopped talking to me entirely when we were in front of patients. He stopped teaching me. At what would become our last meeting together, he refused to acknowledge my concerns about a clinical issue. It seemed like he was trying to pick a fight with me. We fell silent. He looked at me with amusement. I glared at him.

“Are we done?” I still felt like I needed his permission to leave.

“Yup!” He grinned. It was clear I had to talk with my residency director.

She believed me. She was swift and immediately pulled me from the rotation.

One of my fellow trainees, a robust man who played football in college, was assigned to work with him for the following six months.

My fellow colleague believed me. He was swift. He objected and asked for another rotation, stating that he didn’t feel comfortable working with a physician who had mistreated another trainee.

The psychiatrist ultimately left the institution, following an administrative leave.

Sexual harassment occurs in every profession, even medicine. To stop this, we need as many people as possible — men, women, colleagues, advisers and leaders — to support women and act swiftly when these events occur. I was fortunate, but not all women are.

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.