Author: Maria Yang, MD

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Education Medicine Policy Systems

Inspiration from the Surgeon General.

Somehow people knew he was about to enter the room. The thirty or so people in the room were seated, though people began to stand up.

“Are we supposed to stand up for the Surgeon General?” I asked the person sitting next to me.

She shrugged. If we remained seated, everyone would have noticed. So we stood up.

“I’ve been in this position for a year and a half,” Dr. Murthy said, “and I’m still not used to people standing up for me. Please sit down.”[1. I learned later that the Surgeon General has the rank of a Vice Admiral, as the role oversees uniformed health officers. That’s why people stand up for the Surgeon General.]

We were all in that room for about an hour, but Dr. Murthy said little. After some opening remarks about the Turn the Tide initiative related to the opioid epidemic, he asked the audience to tell him what was going well and what could use improvement.

I had never met him before, but I was immediately struck with his listening skills. It was as if he was taking a history from a multi-person patient. He made and held eye contact. He didn’t fidget. He spoke in a quiet yet firm voice. Though he didn’t come across as warm, it was clear that he was interested in and paying attention to whoever was talking to him. His thoughtful follow-up questions indicated that he was listening to what people were saying to him.

He seemed like a good doctor.

As I had never met a federal official before, I later learned that Dr. Murthy was also unusual in that he took notes. (Fun fact: He’s left handed.)

“These are usually publicity events without a lot of substance,” a more seasoned co-worker commented.

By the time the meeting was over, he had covered a sheet from a yellow notepad with copious notes. He expressed what seemed like genuine thanks to us for our time and perspectives.

It was through luck only that I was there. A colleague told me a few days prior that the Surgeon General was scheduled to speak to a local task force related to the opioid epidemic.

“The Surgeon General?” I blurted. “I’d love to hear what he has to say.”

“Then you should come.”

“What?”

Afterwards, as the Surgeon General’s staff were trying to hustle him out the door, the same colleague who invited me to this event gave me A Look. Only I could see the thought bubble above his head: “Go ask him for a photo!”

Though I appreciated Dr. Murthy’s humility, thoughtfulness, and professionalism, I was also grateful and amused with his willingness to stop for a photo.

Earlier that day I was seeing patients.

“Do you know how much longer you’re going to be jail?” I asked.

“Ten or eleven days.” He looked at my left hand. “You’re married?”

“Yes.”

“I should start going to NA meetings again. I’m never gonna meet a woman in here and I get so depressed about not having a family. I want a wife and kids, like my brother. I don’t know why he got so lucky and I got screwed. The TV doesn’t talk to him, he’s got a wife and three kids, God blesses him, but I will wait because the meek shall inherit the earth—”

“What do you think will help you not pick up when you get out?”

He shrugged. “I still don’t have a place to live. Dope helps me feel better.”

We looked at each other and said nothing.

The reality is that the Surgeon General (or any other public official) is just one person. Though he has a grand title, he alone cannot make improve health care. He is part of a system. We can only hope that he and his office will be able to shift the system—even if only just a bit—so that it works better to serve the US population.

What the Surgeon General can do and, at least for me, has done, is inspire physicians to get involved and do better. He could have swept into the meeting and spoke at length about his accomplishments and his status within the federal government. He instead presented himself as a humble ambassador and servant. He demonstrated interest in what our locality has witnessed and experienced. He recognized that, even though he was an academic physician, he is now too far removed from clinical care to speak first as an expert. He solicited and accepted feedback, some of which was discouraging. He was professional. He wasn’t defensive. He acknowledged that it may seem like our feedback would disappear into a void in Washington, DC, though everything else he was actually doing during the meeting gave us hope otherwise. It’s quiet leadership.

There are a lot of problems with health care. Physicians and patients both know this. Physicians are trained to take care of people, not to create and manage financial systems that should only support the relationships between physicians and people. However, if physicians are not involved in the conversations about these systems, then we are not advocating for the patients we serve and the profession that gives us the privilege of doing so. Yes, I know we’re too busy taking care of patients to participate in these conversations that can seem bloated and irrelevant. However, if we don’t get involved to define the problems and solutions, how could we ever expect these systems to improve?

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Observations Reflection Systems

Black Lives are Also Lives.

For the past few weeks I have felt discouraged about ongoing local, national, and global violence. I felt powerless to do anything—including write—to help make things better. I could not find the words to express my sorrow.

So I turned to Buzzfeed.

I came across an article describing the efforts of Asian-Americans who were writing letters in their respective Asian languages to their parents about Black Lives Matter. My father and I hadn’t discussed the deaths of Philando Castile and Alton Sterling. However, the topic of race in America comes up in our conversations every few months.

Several months earlier, while discussing experiences of racism in his life, my father commented, “The Chinese should not be surprised to experience racism. We made the choice to come to America. It was voluntary. Black people didn’t have a choice. They were forced to come here.”

It was a perspective that I hadn’t considered before. And while I understood his point, I wondered what degree of racism any person should experience without feeling “surprise”.

It was only recently that I understood that some people who hear “Black Lives Matter” interpret that to mean “Only Black Lives Matter”. Thus, the rebuttal “All Lives Matter” came into being.

Of course All Lives Matter, I thought. That’s the whole point. Perhaps it would be more precise to say Black Lives Matter, Too.

I asked my dad if Black Lives Matter was receiving as much media attention in Taiwan and China as it was here in the US. I also expressed my surprise about the rebuttal of “All Lives Matter”.

“The Chinese media talk about it in a different way,” he said. “It’s not ‘Black Lives Matter’. It’s ‘Black Lives are Also Lives.’ It’s more clear.”

Indeed! There is no pithy retort to that. The clear implication is that we, as a society, value lives. The death of a Black life should disturb us as much as the death of any other life.

For all of us who are ever considered The Other—and everyone, at some point, is considered The Other—we must support the other Others.[1. We support other Others if their causes are noble and just. Make no mistake: I am not saying that we should support The Others who advocate for genocide, torture, etc.] There was a time in the US when The Majority were fearful of the Chinese, which resulted in the Chinese Exclusion Act. This was the first law that explicitly stated that a specific ethnic group could not immigrate to the United States. Though this law was ultimately overturned in 1943 (not even 100 years ago!), the Chinese are still the only ethic group specifically named for exclusion in the United States Code.

People who were not of Chinese descent disagreed with this law before, during, and after its implementation. They also supported its repeal.[2. I understand that some people opposed the Chinese Exclusion Act solely for commercial reasons. They did not care about equality. I’m not talking about those people.] I am grateful that they spoke up. Had they not, my parents would not have been able to immigrate to the US, contribute to this society, enjoy what America has to offer, and raise a daughter who now writes this blog.

We all speak up in our own ways: Some people participate in protests; others write words for others to read; still others have quiet conversations about it. Advocacy takes many forms. Choose what works best for you.

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Consult-Liaison Informal-curriculum Medicine Observations Reading

Psychiatrists and Demonic Possession.

A colleague sent me a Washington Post article, “As a psychiatrist, I diagnose mental illness. Also, I help spot demonic possession.”

After the author lists his credentials as a psychiatrist, Dr. Gallagher explains why he believes that some people who demonstrate unusual behaviors do not have psychiatric conditions, but are actually possessed by demons.

The sheer number of comments (over 2300 as of this writing) tells me that many people had strong reactions to this piece. (Or perhaps the bulk of comments are vitriolic arguments, name calling, and other unfortunate aspects of communication on the internet.)

It appears that Dr. Gallagher and I share some general principles when it comes to psychiatric diagnosis. For example, he notes:

I technically do not make my own “diagnosis” of possession but inform the clergy that the symptoms in question have no conceivable medical cause.

Indeed, one of the most important services psychiatrists can provide is giving an opinion about whether someone has a psychiatric condition or not. A common saw in medicine is that diagnosis guides treatment. Incorrect diagnosis can lead to incorrect treatment which, at best, will do nothing or, at worst, will harm someone.

Say a man is thrashing around the room, shouting nonsense, and looks confused and angry. The cause of his behavior is low blood sugar. If, however, all the physicians in the room assume that this man has schizophrenia, then instead of giving this man some form of sugar, they may instead give him a variety of tranquilizers.[1. In practice, people with low blood sugars who are behaving this way often receive both tranquilizers and sugar.]

Sometimes people may not recognize that a psychiatric condition is present, which can delay useful treatment. Sometimes people assume that a psychiatric condition is present, when in fact it is a medical condition. Sometimes people assume that a psychiatric condition is present, when in fact it is a variant of human behavior.

As I’ve written many times in the past, though, context matters. Where I believe Dr. Gallagher has taken a misstep is his assured belief that, if these individuals don’t have a psychiatric condition, then they must have demonic possession.

All of his referrals come from clergy who believe in demonic possession. To his credit, Dr. Gallagher does comment

I’ve helped clergy from multiple denominations and faiths to filter episodes of mental illness —– which represent the overwhelming majority of cases —– from, literally, the devil’s work. (emphasis mine)

In medical parlance, then, the chief complaint for his referrals is always “does this person have a psychiatric condition?”. It appears that the answer is often “yes”.

I must comment, though, that I cringed when I read some of his descriptions of people with psychiatric conditions. For example, he describes some of these people as

histrionic or highly suggestible individuals, such as those suffering from dissociative identity syndromes

I will assume that he has no ill will towards “histrionic or highly suggestible individuals”, though no one wants to be described as either. It’s not clear to me if he believes in the construct of “dissociative identity syndromes”. I am skeptical.

He also describes some of these people as

patients with personality disorders who are prone to misinterpret destructive feelings, in what exorcists sometimes call a “pseudo-possession,” via the defense mechanism of an externalizing projection.

Perhaps I underestimate the fund of knowledge the general public has about psychoanalysis. I had to read this sentence twice at a slow pace to understand what he was trying to say. If you believe in psychoanalytic theory, then, yes, that sentence makes sense. If you don’t believe in psychoanalytic theory, then that sentence might make as much sense as demonic possession.

If the answer to the question of “does this person have a psychiatric condition?” is “no”, though, then it appears that the only other option Dr. Gallagher considers is demonic possession:

This was not psychosis; it was what I can only describe as paranormal ability. I concluded that she was possessed.

This is dangerous, whether we’re talking about medicine or any other field. The moment you limit your options, you overlook evidence that supports other ideas and focus only on evidence that supports your theory. This is also called confirmation bias.

The following list may be absurd, but for the sake of illustration, is the only possibility that the “self-styled Satanic high priestess” is possessed by a demon? What if:

  • she is an alien?
  • her previous devotion to the Catholic faith has turned into contempt, so she is using her abilities to combat the faith?
  • she has excellent skills in “reading” other people and senses that Dr. Gallagher may be “histrionic or highly suggestible” to the ideas of demonic possession?

In medicine we often speak of the importance of “having a wide differential diagnosis”. Yes, the man described above who was thrashing around the room, shouting nonsense, and looked confused and angry could have schizophrenia. He could also have low blood sugar. Or he might:

  • have dangerously high blood pressure
  • have an infection in or around his brain
  • not be getting enough oxygen
  • be bleeding in his brain
  • be intoxicated with illicit drugs
  • be experiencing toxic effects from a poison

If we’re only thinking about a few of those things on that list, we might miss everything else. And all the things on that list can lead to the man’s death.

Do I think it is possible that people are possessed by demons?[2. My initial experience with Catholicism was spending hours in debates with my college roommate about transubstantiation. She, raised in the Catholic faith and able to recite Catholic prayers while falling asleep, insisted that the Communion wafer was literally the body of Christ and the wine was literally his blood. I insisted that this was physically impossible. These debates then wandered into other differences in Catholicism compared to other Christian faiths (faith versus good works, etc.—to be clear, I’m a big fan of good works).] Maybe. Is “demonic possession” high on my list of possibilities? No. Do I think that people experience spiritual distress? Yes. Do I think Dr. Gallagher has done an excellent job of promoting his forthcoming book about demonic possession? Absolutely.

Categories
Observations Reflection Systems

Us and Them and Homicide.

If an event doesn’t happen often, it’s difficult to predict when it will happen next. We can only talk about “risk factors”.

For example, no one can predict when an earthquake will occur. We can, however, talk about the risk of an earthquake. We know that the risk of an earthquake is much higher in Seattle than in Houston: Seattle is on a fault line while Houston is not. Because earthquakes are rare, though, we don’t know when Seattle will have an earthquake. We just know that it’s more likely to happen there than in Houston.

Homicide is also a rare event. In 2013, about five out of 100,000 people died from homicide. That means 99,995 out of 100,000 people did not die from homicide that year.[1. A reader told me that these numbers are confusing. More than 100,000 people died in the US in 2013. My point is that the vast majority of people don’t die from homicide. Communication is hard.] Compare that with suicide: In the same year about 13 out of 100,000 people died from suicide. That’s right: In the US, people are over twice as likely to kill themselves than other people.

Because homicide is such a rare event, it is difficult to predict when, where, and how it will occur. We can discuss risk factors (e.g., alcohol and other substance use; access to firearms; gang involvement; exposure to domestic violence and child abuse; previous history of fighting of violence), but none of those risk factors will help us predict when it will happen. There are adults who were beaten as children, drink alcohol now, and own a firearm… but they will never kill anyone.

The data is mixed about the association between mental illness and homicide.[2. Here are three papers that discuss mental illness and suicide:

] Based on numbers alone, though, it is both inaccurate and unfair to state that homicide is due to psychiatric conditions alone:

Compare that to the rate of homicide: 5 out of 100,000 people.

With increasing news reports of people killing others, my colleagues and I have wondered how we can intervene. Many people who have committed homicide have never encountered the mental health system. Even if they did, they may not have endorsed or demonstrated symptoms that would warrant any intervention, including a follow-up visit. We agree that individuals who kill others are disturbed, but they may not have a “mental illness” that is described in our field. (We then wonder: So what is going on with them?)

The book The Spirit Level describes the correlation between greater interpersonal violence in societies with greater inequality. The authors also show evidence of higher prevalences of psychiatric disorders, obesity, and teen pregnancies in societies that are more unequal.

While it is easier to attribute these acts of heartbreaking violence to individuals—They are the problem; this happens because They are “mentally ill”; Their religion dictates that They should kill people; We would never do that—perhaps we should attribute this violence to our society and our communities (or lack thereof).

How would our society function if everyone had food, clothing, and a home? What would happen if everyone had steady employment and income? How would relationships change if everyone in school and at work learned how to recognize their emotions and practiced coping skills? What would happen if people didn’t drink, use drugs, or resort to violence when feeling distressed? What would shift if everyone had the chance to go to school and learn about different people, places, and ideas? How would things be different if people didn’t feel hopeless and helpless? What if people believed their communities could create something better? What if people didn’t believe that the only solution involves destruction?

It is easy to blame Them: They have mental illness; They believe in a religion that is false; there is something wrong with Them.

They and We, however, are part of the same community. Until we realize that we must work together to reduce risk factors and help each other, we cannot expect that these tragic events will stop.

Categories
Medicine Observations Reflection

My CV of Failures.

Several people on Twitter and Vox recently discussed “CVs of failure“.

We don’t like to share our failures, though we often don’t realize how our failures resulted in opportunities. (Or maybe that’s the narrative we tell ourselves so our failures don’t sting as much.)

Someone who provides wise counsel to me commented that sharing a CV of Failures is much easier to do when you’ve achieved success. I can see his point, though would argue that sharing a CV of Failures more reflects self-acceptance than success. Some people don’t ever think they’ve achieved success even though everyone else thinks they have.

So, in case it does provide inspiration for others, here’s my informal and abridged[1. This is most certainly an abridged version of my failures because (1) this includes only the professional failures I can remember, and (2) it includes strictly “professional” failures.] CV of Failures:

Universities I Did Not Get Into[2. Patients rarely ask me where I went to college or what I studied.]

  1. Stanford University
  2. Harvard University

Medical Schools I Did Not Get Into[3. Patients are even less likely to ask me where I went to medical school. The people who most frequently ask this question are physicians who work in academic settings.]

  1. University of California, Los Angeles (I cried)
  2. University of California, San Diego
  3. University of California, Irvine
  4. University of California, San Francisco
  5. Loma Linda University
  6. Stanford University
  7. Johns Hopkins
  8. Vanderbilt University
  9. Northwestern University
  10. Georgetown University
  11. New York Medical College
  12. Baylor University
  13. Tufts University
  14. Albert Einstein College of Medicine
  15. Case Western Reserve University
  16. Wake Forest University
  17. Mayo Medical School
  18. MCP Hahnemann University (now Drexel University)

I can’t remember the other schools I applied to. All told, I applied to 28 schools. Two offered letters of acceptance.

Residencies I Did Not Get Into[4. I don’t think any patient has ever asked me where I did my residency.]

Applicants “match” into a residency. Medical students apply and interview at residency programs. They then make a rank list of where they want to go. Programs also generate a rank list of medical students they want. A computer then “matches” the lists.

The lore is that “good” students will match into one of their top three choices.[5. Somebody who interviewed me at one of those programs actually asked me during the interview: “Were you abused as a child?”] I did not.

  1. New York University
  2. University of California, San Francisco
  3. Mount Sinai School of Medicine

Places That Rejected My Essays[5. I compare this list to the list of medical schools I applied to and realize that I should submit more essays. More attempts may lead to more failures, but increases the likelihood of actual success.]

  1. Bellevue Literary Review
  2. New York Times
  3. Salon
  4. Slate
  5. Vox

As a total aside, there was a time when I did not list my blog on my actual CV. About five years ago I did. I wish I had sooner.