Author: Maria Yang, MD

Categories
Consult-Liaison Education Medicine

Foundations.

I never did follow up here on the talk I gave to attorneys about “Psychiatry 101“. Teaching the foundations of any subject is both challenging and rewarding. It is also an excellent way to remind ourselves of the importance of the basics. Foundations anchor and guide us, particularly when we start getting lost in complex or unusual situations.

During my talk I review the definition of “mental disorder”.[1. I dislike the term “mental disorder”, primarily because of the stigma attached to it. The term focuses on what is wrong, not what is going well. We also get so caught up talking about “disorders” that we stop talking about “people”.] DSM-5 states that a mental disorder has two components:

  1. disturbance in cognition, emotion regulation, and/or behavior (the assumption is that pathology in the brain/mind manifests as this disturbance)[2. The underlying assumption that “disturbances” reflect pathology in the brain/mind is up for discussion, given that we don’t know if there is a distinction between the brain and the mind. The two seem related, but how they are related remains unclear. Furthermore, some people would argue that not all disturbances represent pathology. Context matters. People who choose not to eat during a hunger strike against the government are demonstrating a “disturbance” in behavior. Does that represent pathology?] AND
  2. the disturbance leads to distress OR impairment/disability

Both conditions must be met. However, the second criterion has two parts. This complicates the definition of a mental disorder. Distress does not equate to disability. People can experience low distress and high disability: Consider the person who has lost all his relationships and is unable to hold a job because he believes that he is the Messiah. People can also have high distress and low disability: Take someone grieving the loss of his spouse.

Symptoms help define diagnosis, and diagnosis guides treatment. Danger arises when psychiatrists treat symptoms without a clear diagnosis. An analogy: Say you are lost in a city. You call your friend to pick you up.

“Where are you?” your friend asks.

“I don’t know,” you respond.

“What street are you on?”

“Main Street.”

“Main Street and what?”

“Um… Main Street and Popcorn Alley.”

“Okay. Stay there are I’ll be there in about 15 minutes,” your friend says to your relief. You and your friend were able to define where you were located, which allowed your friend to figure out how to get from his house to Main Street and Popcorn Alley.

But what is the conversation went like this?

“Where are you?” your friend asks.

“I don’t know,” you respond.

“What street are you on?”

“I don’t know. The streets don’t have signs on them.”

“Okay. What do you see around you?”

“Uh… there’s a coffee shop on one corner and a sandwich shop on the other corner.”

“What else do you see?”

“Well, there’s a parking lot across the street.”

At best your friend would probably express gentle frustration with your lack of clarity: There are many coffee shops, sandwich shops, and parking lots in the city. How is he supposed to find you with such vague directions? At worst your friend would say, “Okay, I’ll find you,” and then hop into his car and drive around, looking for the triad of coffee shop, sandwich shop, and parking lot. The diagnosis (location) is unclear, so the treatment (picking you up) is also unclear (and frustrating and wasteful).

There is variability in how psychiatrists approach diagnosis of a “mental disorder”. The criterion of “disturbance in cognition, emotion regulation, and/or behavior” is often the easier of the two to determine: Most people would agree that people who cut themselves, refuse to eat, or feel so hopeless that they literally can’t get out of bed are experiencing a “disturbance”.

If the disturbance leads only to distress, but not disability, does that mean a mental disorder is present?

Here are several instances of disturbance AND distress WITHOUT disability:

  • hearing voices say unusual things to you
  • having self-doubts and feeling terrible following a breakup
  • suspecting others of sabotaging your work

If these things happen to you, does this mean you have a mental disorder? Maybe, but not necessarily.

Here are several instances of disturbance AND impairment WITHOUT distress:

  • hearing voices say that you are God and that you should touch everyone to bless them
  • having beliefs that you do not need to eat or drink to live; air alone will sustain you
  • suspecting others of sabotaging your work, so you stop going into the office, never talk to anyone, and don’t share any of your data (some distress is probably associated with this)

If these things happen to you, does this mean you have a mental disorder? The impairment component makes it more compelling that a disorder is present. (Why, yes, I know my bias is showing.)

If we do not exercise diligence in our diagnosis of a “mental disorder”, then we may suggest an intervention that is incorrect or insufficient. Even worse, the treatment may be unhelpful or harmful.

We work with our patients to discern whether a mental disorder is, in fact, present. Together we then clarify what the mental disorder is. Lastly, we survey possible interventions.

This is the value of returning to foundations.

Categories
Reading

Interesting Internet Items Over the Past Week.

I try to read more books instead of stuff on the internet.[1. The only way I successfully motivate myself to read more books is to keep a log of what I’ve read. I’m doing better this year than I did last year, but I still wish the list were longer. These are the books I’ve read this year thus far, where recommendations are in bold:
Influence (Cialdini)
Obvious Adams (Updegraff)
Your Illustrated Guide to Becoming One with the Universe (Sakugawa)
Essentialism (McKeown)
King Solomon’s Ring (Lorenz)
When Things Fall Apart (Chodron)
Seven Habits of Highly Effective People (Covey)
The Wisdom of No Escape (Chodron)
Shelter for the Spirit (Moran)
Gone Girl (Flynn)
Toyota Kata (Rother), but did not finish
No Exit (Sartre)
The Ten Golden Rules of Leadership (Soupios)
The Lessons of History (Durant)
Pebbles of Perception (Endersen)
The Stranger Beside Me (Rule)
Yoga Wisdom at Work (Showkeir)
and One Day in the Life of Ivan Denisovitch as listed above.] I recently finished (and recommend with enthusiasm) One Day in the Life of Ivan Denisovitch, which is both depressing and amusing. I put it in the same category as Frankl’s Man’s Search for Meaning, a book I consider essential reading for everyone.

Here are some interesting items from the internet, rather than books, I read over the past week:

The Ghosts in Our Machines

When’s the last time you’ve spotted someone you know on Google Maps? I never had. And my mother, besides, is no longer alive. It couldn’t be her.

Strong Placebo Response Thwarts Painkiller Trials

But the finding that placebo responses are rising only in the United States is the most surprising aspect of the latest analysis.

How Government Killed the Medical Profession

Once free to be creative and innovative in their own practices, doctors are becoming more like assembly-line workers, constrained by rules and regulations aimed to systemize their craft.

The Violence of Algorithms

Much of the data used was inputted and tagged by humans, meaning that it was chock full of human bias and errors. The algorithms on which the system is built are themselves coded by humans, so they too are subjective. Perhaps most consequentially, however, although the program being demonstrated was intended to inform human decision-making, that need not be the case.

Categories
Observations Reflection Seattle

10,000 Windows.

“I think I can see 10,000 windows,” my dad said as we looked out of his apartment. On the other side of the glass was a view of downtown Seattle.

“10,000?” I did not mask the incredulity in my voice. “Is that a good thing?”

“Yes, it is,” he replied. “More windows means more people. We all need people in our lives. According to feng shui, the more windows you can see, the more influence, more popularity you will have.”

“But 10,000?” I asked again.

“Yes,” he said. “I can see the Columbia Tower and that alone has several hundred windows. Think about all the other windows of the skyscrapers….”

“Yes,” I said. “10,000 windows.”

We had lunch at a hole-in-the-wall restaurant in Chinatown. He expressed his pleasure with the food to the waitress. She had immigrated to the US about ten years ago. My father had immigrated to the US nearly 45 years ago. When he spoke to her in Mandarin, he used a phrase to describe his immigrant status that I didn’t understand.

“There’s a special term for us,” he said. “We were born in China, so when we fled to Taiwan [to escape the Communists], we were considered ‘mainlanders’. We were different. Not everyone from Taiwan had the opportunity or means to immigrate to the US. So we were considered different again. When we immigrated to the US, we were considered ‘Chinese’ and still different—”

“—an alien no matter where you went,” I finished.

“Yes!” my father exclaimed with a smile.

My father always insists on picking up the bill when we go out to eat. He and the waitress began talking again:

“Have you lived in Seattle since you immigrated?” the waitress asked.

“No, I moved up here to be with her,” my father said as he pointed to me. “She’s my daughter. My wife passed away last year.”

“Oh. She was born in the US, wasn’t she?”

“Yes, I was born here,” I answered in Mandarin. “That’s why my Chinese isn’t very good.”

“It’s not that your Chinese isn’t very good. You speak with an American accent,” the waitress said to me. Turning to my father she continued, “She’s very well-mannered. I could tell when you both walked in.”

Suddenly, I was eight years old again. I sat still, said nothing, and kept my face neutral. This is what you’re supposed to do when your elders say nice things about you.

My father nodded and smiled. “She is courteous; she has class.” After taking a sip of tea, he continued, “My daughter is also a doctor.”

I winced. They only saw me blink.

Daughters must be humble so their parents can show their pride. I swallowed my embarrassment with my tea.

My mother used to do that all the time, too: Out of nowhere she would tell strangers that I was a physician.

“Why do people need to know?” I used to complain. It never changed their behavior, so I stopped sharing my objections with them.

There are now other things I don’t share with my father.

“How’s work?” he asks.

“Work is fine,” I say. Work is always fine. I don’t tell him the terrible things patients have said to me. I don’t tell him about the injustices of the system: Was it designed this way? Are these perverse outcomes from good intentions? I don’t tell him that I hustled him into a restaurant to avoid an encounter with a patient I worked with in jail.

Every time we see each other I tell him I love him—a brash thing to do in a culture that values stoicism. I don’t tell him how anxious I feel when he doesn’t respond to my text messages within an hour: Did something happen to him? Is he okay? Did he die?

I don’t tell him how I still feel sorrow for the the death of his wife. I simply cannot imagine his loss.

He must know, though, just as I know about the heartache he still feels. It’s in his face, the way he looks into the distance, as if the past was just beyond the horizon.

We instead go out to lunch. I let him buy it for me and listen to him speak of the beauty and power of 10,000 windows.

Categories
Lessons Medicine Reflection Systems

Reflections on Psychiatry.

A medical student named Anthony sent me an e-mail and asked:

Are [the items listed below] things that have nagged at you during your training or as a psychiatrist now? How do you deal with the ambiguity of psychiatry, or do you find that as your clinical experience grows, you find yourself more reassured in what you do from seeing your patients improve? Where do you see psychiatry going in the next couple of decades? I understand these are big questions, but I feel it would be incredibly helpful to hear from someone who’s been practicing for a while.

Indeed, these are big questions, but the big questions make us reflect on what we do: What is the point? Why do we bother? Are we doing the “right” thing?

Are these things that have nagged at you during your training or as a psychiatrist now?

The things Anthony listed as frustrations—the primacy of the biological model, the lack of novel and consistently effective medications, the role of medications and pharmaceutical companies, the medicalization of “normal” human experience—resonate with me, too. These things bothered me while I was in medical school, irritated me when I was a resident, and continue to vex me as an attending.

What bothers me the most is how psychiatry can become an agent of social control. Psychiatry can lend its vocabulary and constructs to authorities to oppress or exclude certain populations.

Consider the spate of school shootings. If we label the shooters as “mentally ill”, that distracts from the culture of fear and violence. Homosexuality was a legitimate psychiatric diagnosis until 1973. African Americans are more likely to receive diagnoses of schizophrenia.

Words are powerful. The ramifications of diagnosis are serious. We must not forget how our words can affect how people perceive themselves and how others treat them.

This overlaps with the medicalization of human experience. Is it okay that people receive Xanax from physicians when they are grieving the death of a loved one? Is it okay that students receive Adderall from physicians when they are striving for academic excellence? Is it okay that people from other cultures receive antipsychotic medication from physicians when they report hearing the voices of their ancestors?

My discomfort with this has affected my practice: I purposely choose to work with people who exhibit symptoms that rarely overlap with the general spectrum of human experience. Most people do not believe that someone has stolen their internal organs. Most people do not drink a fifth of alcohol each day to cope with guilt and shame. Most people do not fear that aliens will execute them if they move into housing from the streets.

A natural consequence of working with this population is that advocacy becomes a large part of the work: People with severe conditions can and do get better. Most people enter medicine to help people, to see people get better. The gains in this population may take longer and sometimes may not be as great as in other populations, but they do occur.

How do you deal with the ambiguity of psychiatry, or do you find that as your clinical experience grows, you find yourself more reassured in what you do from seeing your patients improve?

I learned early on that, if I don’t know the answer, the best thing to do is to say, “I don’t know.” It can be hard to say that out loud because we don’t want to admit our ignorance to ourselves or to others. Perhaps the difficulty isn’t the ambiguity of psychiatry. Maybe the challenge is managing our own vulnerability.

This is how I deal with the ambiguity:

  • I remind myself that it is impossible for me—or for anyone—to know everything. That doesn’t mean I give up and walk away: I do the work to learn as much as I can. The learning never stops, even when I want it to.
  • I remind myself that I will mess up. I hope that I will make fewer mistakes as I advance in my career, but I trust that I will screw up. I also hope that I will have the wisdom and humility to learn from my errors and avoid them in the future.
  • I remind myself to “First, do no harm.” I may feel pressure[1. Know that the system will often put pressure on you to “do something”. That doesn’t mean the system is right. Unless someone is dying in that moment, there is always time to stop and think.] to “do” something—prescribe a medication! send someone to the hospital! intervene right now! There is always time to pause and consider: “Will this cause (more) harm?” To be clear, I don’t advocate living life through avoidance. Sometimes the way to navigate ambiguity is to avoid actions that will make things worse.

I’m sure this isn’t the first time you have heard an attending say this: The farther along I go the more I realize how little I know. There is so much more for me to learn.

Where do you see psychiatry going in the next couple of decades?

Experts are much better at describing base rates than they are at predicting the future.[2. This idea about base rates and predictions comes from the book Decisive, which I recommend with enthusiasm.] This is an important question that deserves more reflection. Different ideas spin in my head: Psychiatry will have to reconcile with people who have experienced mistreatment from our field. Psychiatry must examine social determinants of health and scrutinize how they affect diagnosis and treatment. Psychiatry must collaborate with other fields and cannot expect that isolation will actually help patients, our colleagues, or the specialty.

For you (and me) I would add that we cannot expect to influence or change a system if we do not take part in it.[3. Full disclosure: I am not a member of the American Psychiatric Association. My values do not seem to align with theirs. However, who am I to complain about the values of the APA if I’m not willing to help shift them? And how can I contribute to any shift if I do not join them?]

Good questions, Anthony. I encourage you to ask other psychiatrists these same questions. Regardless of which field you choose to enter, I hope you continue to exercise curiosity and healthy skepticism of the work you do. This will not only help you grow as a person and physician, but will also help your patients and field of expertise.

Categories
Education Funding Policy Systems

Jail Costs versus Hospital Costs.

We received the State of Washington Voters’ Pamphlet in the mail today. One of the initiatives, I-1401, concerns “trafficking of animal species threatened with extinction”.

Have no fear: This post is unrelated to trafficking of animal species threatened with extinction.

The “Fiscal Impact Statement” includes a statement about jail costs (highlighted for emphasis):

jailcost

“No wonder why people with psychiatric conditions end up in jail!” I exclaimed. “It’s so much cheaper for them to be there!”

Information about hospital costs are public. This page shares inpatient hospital rates for people who have Medicaid insurance in August 2015. All the hospitals in Washington State are listed in the leftmost column. One of the columns has the title “Psych_ Per Diem”. That column tells you how much money each hospital is paid if a patient with Medicaid is admitted there for psychiatric reasons. First, you will note that hospitals are paid[1. Forgive the passive voice when I write “hospitals are paid”. In Washington, hospitals send bills for Medicaid patients to the state. The state pays the hospital bill. The state then turns around and sends a bill to the region that the patient “belongs” to. The region then pays that state bill. The region gets money to pay that bill from a mix of federal and state Medicaid dollars, which ultimately come from taxpayers. Confusing, right?] different amounts. That alone is fascinating—what accounts for that? who decides how much money each hospital will receive?

More to the point, it costs anywhere between $711.55 and $1788.93 per day for an adult with Medicaid to stay in a hospital. The average cost of incarceration in Washington is $88 per day. Thus, it is at least eight times cheaper for someone to stay in jail than in a psychiatric hospital.[2. This page shares inpatient hospital rates for people who don’t have any insurance. Note that the rates are lower compared to the Medicaid rates. They are nonetheless still much higher than the daily jail rate.]

On the one hand, the differences in cost aren’t surprising: Hospitals often have more staff, equipment, and services. On the other hand, we also know that jails are often the largest psychiatric hospitals in any given region. For example, in Seattle, the jail has about 120 psychiatric beds. The largest psychiatric hospital in Seattle has about 61 beds.

I really want to believe that no one intentionally designed the system this way. Surely no person or system could be so heinous and miserly to funnel people into jail instead of a psychiatric hospital. Right?

Right?

But, then the disgust kicks in: What if the costs were reversed? What if it cost $88 a day for someone to stay in a psychiatric hospital and $712 a day for someone to stay in a jail? Would we see as many people with psychiatric conditions in jail? Of course not.[3. To be clear, we should also help people stay out of psychiatric hospitals, too. Inpatient services should be available if people need them, but let’s focus on prevention and help people stay in their communities. Being in a hospital generally sucks.]

It shouldn’t be all about money, but when the cost differences are that big, money has undue weight. If we actually want to help people with psychiatric conditions, we must pay for services. Otherwise, we will only see more and more of them in jail.