Author: Maria Yang, MD

Categories
Education Informal-curriculum Lessons Medicine Observations Reflection Systems

Thoughts on the Movie “Get Out”.

Have you seen the movie Get Out? If you haven’t, what follows might spoil part of the movie for you. You might want to watch it before reading this.

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

We learn early on in the movie that Rose’s mother is a psychiatrist. Chris, Rose’s boyfriend, asks something like, “She’s a psychologist?”

The response Chris receives is something like, “No, she’s a psychiatrist.”

While I can’t know for sure, I believe that the writer of the film, Jordan Peele[1. If you are not familiar with Jordan Peele, please go watch some clips of Key and Peele.], wanted to highlight the difference between the two. Psychiatrists are physicians. And some physicians, under the guise of expertise, have promoted racist ideas.

Dr. Samuel Cartwright was a physician who practiced in Alabama, Mississippi, and Louisiana in the years leading up to the American Civil War. He defended slavery and wrote pieces that argued that blacks were inferior to whites.

One of his articles, “Diseases and Peculiarities of the Negro Race“, describes “drapetomania, or the disease causing Negroes to run away”. Because he describes drapetomania “is as much a disease of the mind as any other species of mental alienation”, it is clear that this is a psychiatric condition, such as kleptomania (compulsive stealing), pyromania (compulsive fire-setting), and dipsomania (the old name for alcohol use disorders).

In this article Dr. Cartwright asserts that God has ordained blacks as “submissive knee-bender[s]” and are “intended to occupy… the position of submission”. To support that blacks were destined to be “submissive knee-benders”, he states that “in the anatomical conformation of his knees, we see [it] written in the physical structure of his knees, being more flexed or bent, than any other kind of a man.”

To prevent the development of drapetomania, he states:

if his master or overseer be kind and gracious in his hearing towards him, without condescension, and at the same time ministers to his physical wants, and protects him from abuses, the negro is spell-bound, and cannot run away.

In Get Out, Chris (plus Georgiana, Walter, and Andrew) becomes obviously “spell-bound” through the hypnotic powers of the porcelain cup and silver spoon. One could argue that Rose is demonstrating faith in this practice as she was initially “kind and gracious”, “without condescension”, “ministers to his physical wants”, and “protects him from abuses” (remember the police officer who pulled them over?).

Dr. Cartwright comments that, in the course of drapetomania, slaves become “sulky and dissatisfied” before they run away. He advises that “the cause of this sulkiness and dissatisfaction should be inquired into and removed, or they are apt to run away or fall into the negro consumption.” However, if slaves were “sulky and dissatisfied without cause,” he states that the treatment was “in favor of whipping them out of it, as a preventive measure against absconding, or other bad conduct. It was called whipping the devil out of them.”[2. Wikipedia also comments that another treatment for drapetomania included “removal of both big toes”, which makes running difficult.]

Chris becomes understandably “sulky and dissatisfied” with his time at the Armitage home and seeks to flee. Though he wasn’t whipped to treat his drapetomania, it’s not a hard stretch to argue that the plan to remove most of his brain (“coagula”) is essentially whipping the devil out of him so that only his body remains.

Dr. Cartwright apparently published these ideas in the New Orleans Medical and Surgical Journal (as well as De Bow’s Review, a magazine of “agricultural, commercial, and industrial progress and resource” in the American South). This publication came from his work as the chairman Louisiana State Medical Convention committee. One of their tasks was to “examine the diseases peculiar to the Black slaves of the antebellum South”.[3. From a Lancet article called “Drapetomania“.] This was a professional medical opinion!

To be clear, not all physicians agreed with Dr. Cartwright’s opinion. Dr. Hunt, a physician who practiced in Buffalo, New York—that is, North of the Mason-Dixon line—lampooned Dr. Cartwright’s concept of drapetomania. He rightly wondered why drapetomania seemed to only exist in the South. He made wry remarks that drapetomania seems to affect the neurons of slaves so that they only flee in a northerly direction. He also pointed out that drapetomania resembled the condition of schoolchildren who ran away from school to play.

In essence, Dr. Hunt shouted, “Context matters!”

Dr. Cartwright sincerely believed that drapetomania was an inherent quality of black people.[4. Dr. Cartwright also described “dysaethesia aethiopica“, or “hebetude or mind and obtuse sensibility of body” that only occurred in blacks in the South.] As he was a fish in the sea of Southern slaveowning culture, he either could or would not believe that social and political context affects the definitions of psychiatric conditions. (He also could not believe that his ideas were wrong.) Maybe Jordan Peele was thinking about Dr. Cartwright and drapetomania when he created the characters in Get Out. Maybe he wasn’t; maybe he was pointing out the consequences and longevity of racism.

Psychiatry has been and can easily become an agent of social control. The moment we begin to think that we’re too good or too smart or too sophisticated to become agents of social control, we and the people under our care are doomed.

It is paramount that we remember this always in the current political climate. May we have the wisdom and courage of Dr. Hunt.

Categories
Medicine Nonfiction Observations Policy Systems

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.

Some have taken leadership roles, only to relinquish them because of fatigue from fruitless discussions with administrators. Others have tried to alert senior managers about dangerous and irresponsible clinical practices. Their efforts were unsuccessful because concerns about finances trumped concerns about clinical services. With a bad taste in their mouths they resigned from their positions. Still others have tried to convince senior administrators about why certain clinical services are necessary. Though these clinical services save money across systems, they do not generate revenue for any specific organization.

“Just keep quiet and keep doing what you’re doing,” they hear from a few senior managers who are sympathetic to their efforts. “Maybe you can stay under the radar that way.”

One had the job duties of three positions. This physician asked for help after recognizing that this workload wasn’t sustainable. The administrators repeatedly said no. And, yet, when this physician finally resigned, the administrators split the single position into three.

“It’s like no one cares about about human suffering. It’s always about money.”

Some have become medical directors, only to learn that senior leadership expect a rubber stamp of agreement from them as figureheads to help change the behaviors of medical staff. Many of their clinical recommendations go unheeded because mandates from policy advisors and economists have primacy. For-profit corporations value profit over patients and seek the counsel only of their shareholders.

They have noticed that administrators often value the “medical doctor” credential for their reports over the clinical expertise of the person with the credential. They recognize that they are often not invited to certain meetings because some administrators do not want to hear what they have to say. They thought that they could offer specialized knowledge to proactively improve systems, but they learned that systems only react to audits.

We all sit around the table, the occasional fork clinking against plates holding desserts. No one talks because no one knows what to say. If we’re all experiencing this across different clinical settings and organizations, what encouragement could we offer?

What do we say to our patients?

Categories
Nonfiction Observations Reflection

(Stupid) Status Games.

I only noticed later that he had a taser on his belt, which means that he was probably a sergeant.

After the doors closed and the elevator lurched into motion, he turned to me and said, “C’mon, smile! It’s not so bad.”

His comment snapped me out of my reverie. I turned my head to look at him and reflexively smiled, though immediately wondered why. His glasses lacked rims and his head lacked hair.

“Are you almost done with your day?” I asked. Maybe he was having a bad day.

He snorted before he glanced at his watch. “Eh… maybe.”

Shift change was in less than 45 minutes.

“Might you have to work mandatory overtime?” The officers I work with often learn of their mandatory overtime shifts about an hour before the next shift begins.

“Ha! No,” the officer laughed. He looked at me again as the elevator reached my floor. “I’ve worked here longer than you’ve been alive.”

Now, in retrospect, I should have let that one go. Maybe he was giving me a compliment: You look young! The sneer in his voice, though, suggested that he wasn’t.

“I think you believe I’m younger than I actually am,” I said over my shoulder as I walked out of the elevator.

“I’ve been working here for 36 years!” he called after me.

“I’m older than that,” I said, without turning my head.

Before the elevator doors slid completely shut, he shouted, “NOT BY MUCH!”

“I’m pretty sure he wouldn’t have said, ‘I’ve worked here longer than you’ve been alive,” if I were a guy,” I complained to my female colleagues.

“Yeah… but, you know, he was right: You’re not much older than 36 years.”

Categories
Observations Reflection Systems

Race.

No one was sitting near us at the fast food chain, but my dad lowered his voice anyway.

“You were three or four years old,” he said. “We were watching an NBA game on TV. You asked, ‘Where are the white people who play?’ Even little kids notice these things.”

“How did you answer my question?”

“I didn’t.”

About 5% of inmates in the jail are in psychiatric housing at any given time. My current post assignment is with males who demonstrate acute symptoms, which comprises about 2% of the entire jail population. A small team works with this 2%.

To be clear, not all people with psychiatric conditions are put in psychiatric housing. Sometimes people start there and, as their condition improves, they move on to general population housing. Some people with psychiatric conditions never come to psychiatric housing. How one behaves, not one’s diagnosis, determines where one is housed.

I don’t know if the racial mix of my patients is proportional to the racial mix of all the people in jail. It’s rare that the patients I care for are comprised of only one race. I have yet to ask, “Where are all the white people?” However, I’ve certainly asked that before in another correctional setting.

I’ve often framed the processes of clinical work as a game. Maybe this is a product of clinical training: When working in hospital services, you’ve “won the game” if you were able to discharge all of your patients. You make informal wagers as to the duration of rounding: “Oh, our attending is Dr. So-and-So, so we’ll finish in less than an hour, tops,” or “Dr. Blah-Blah is on service now. You think three hours? Four? Five?!”

It’s probably just one way of coping.

While on various outreach teams, the objective of the game was to keep all of my patients out of the hospital. When working in a clinic in a medical center, it was to get all my patients well enough so that I could send them back to primary care. Now, the game is to get them out of the most acute unit and prevent them from returning. (The object of the game really should be how to keep people out of jail. That requires coordinated efforts across space and time, particularly for people with complex psychiatric conditions.)

Sometimes my patients are young black males. Sometimes they talk about problems they’ve had with officers or other inmates in the jail.

“I don’t want you to come right back to this unit if we send you out.” That’s how I usually start it. “If someone else gives you a hard time or starts being a jerk to you, what are you going to do to help you stay there and not get sent back here?”

People are often doing much better by the time we’re able to have this conversation. They usually provide reasonable answers.

Even though no one else is sitting near us, I then lower my voice.

“You’re a young black man. Some people here—not everyone, but some of them—react to you in certain ways just because of the color of your skin. That’s not fair, but, sometimes, that’s what happens. You know this much better than I do.”

I remain struck with how their faces soften. Jail is a hard place to be and people adopt hard expressions on their faces. When this coversation happens, these young black men invariably smile, but not from joy.

“So if something happens, you have to figure out how to respond so that you’re not the one who comes back here. Does that make sense?”

Sometimes they thank me for talking about race; sometimes they tell me that they already know what they need to do; sometimes they simply assert, “Don’t worry, I won’t come back here.”

Why do I lower my voice when I talk about this? Would I bring this up if I were a white female? a white male? Does the fact that I look obviously Asian work in my favor? Do I need to bring up something that they already know? Am I just being rude? Do good intentions matter when people find the intentions condescending?

Am I actually helping them when I frame things this way? Or am I only making myself feel better?

It’s a small sample size and completely anecdotal: After we have this conversation, they don’t return to the unit.

Maybe they were never going to come back, anyway.

Categories
Lessons Nonfiction Observations Reflection

On Knowing Yourself.

I know of only two people who, upon starting medical school, knew that they wanted to become psychiatrists. (How did they know what they wanted to do eight years before they did it???) They both achieved their professional goals: One created a community clinic for people with severe psychiatric illnesses. The other became an addiction psychiatrist and now oversees an entire substance use disorder program for a health care organization.

I was not one of those people. As a youth, I aimed for family medicine, a generalist that would help people of all ages. While studying microbiology in college, I aimed for infectious diseases: The ingenuity of single-cell organisms! The science behind antibiotics and antiretroviral medications! The elegance of diagnosis and treatment! (My fascination with microbiology persists.) In medical school, I learned that infectious disease is a subspecialty of internal medicine and, WOW, there are a lot of subspecialities within internal medicine! Oncology (cancer) and nephrology (kidneys) captured my attention for a while—more incredible physiology that occurs on a cellular level!—and, then, seemingly out of nowhere, appeared psychiatry.

We’re biased when we look back at how things unfolded: We can’t change the past, so we tell ourselves that it all worked out the way it was supposed to. So, yes, of course I was supposed to go into psychiatry all along.

It became clear during my psychiatric training that I prefer to work with people who are experiencing severe psychiatric symptoms, particularly psychosis (e.g., people who hear voices saying terrible things about them, people who believe that someone has exchanged their internal organs for someone else’s). I also like the intersection and interplay of physical and mental conditions: Sometimes people who have significant medical illness develop striking psychiatric symptoms, which resolve along with their medical illnesses. Sometimes people with significant psychiatric illnesses develop significant medical problems, and successful treatment of both conditions requires teamwork. Complex problems are fascinating. Witnessing people recover from complicated conditions is rewarding. I’m lucky that I have had the opportunities to do this work.

I’ve also recognized that I am not consistently warm and empathic to people who are experiencing mild psychiatric symptoms. Two previous patients come to mind:

  • “I’m so stressed out,” she said while wringing her hands. She began to pick at the tassel of her Coach bag. “I don’t know which to remodel first: The beach house? the pied-a-terre? or the kitchen in our home? It’s all I think about and I’m starting to lose sleep over this.”
  • “My girlfriend started taking Prozac a few months ago, and it seemed to really help her. She has a lot more creativity. I’m thinking it might help me with that, too. In my line of work, creativity is important and if Prozac will help me with that, I won’t feel as much pressure on the job.”

For the woman with the three properties, we worked through that with minimal use of medications. I’m not proud to say that, for the man who desired creativity, I stared at him blankly when he was done speaking.

It’s important to know yourself. As I understand it, it usually takes at least a lifetime to learn about yourself. Even then, most people never know themselves completely by the time they die.

Learning about yourself helps you recognize how you could do things better or differently. We all have our weaknesses. They exist, even if we wish they didn’t. Everyone else sees them, even though we don’t.

There are many ways to get glimpses of our blind spots. If we’re willing to linger a bit when we catch these glimpses, we have the opportunity to make ourselves more awesome.

However, it’s hard to linger because these glimpses often occur when we’re angry or annoyed. Maybe you make an executive decision for something to happen and a lot of people don’t like it. Maybe you learn that not as many people liked or supported you when you thought they did. Maybe you wish that an institution or a group of people would write or say nice things about you, but they don’t.

How it burns!

These are all opportunities to get to know yourself a little better:

  • What emotion am I experiencing?
  • What happened that led me to feel this way?
  • What do I think the truth is?
  • Is it possible that what I think is true isn’t actually true?
  • What questions could I ask to learn more?
  • What do I think might happen if I start to ask questions?
  • What would it mean to show ignorance?
  • What would it mean if I were wrong?

Wherever you go, you bring yourself with you. Even if you do not yet have any interest in learning about youself, that doesn’t stop other people from learning about you. It is much more humiliating when everyone else knows you much better than you know yourself.