Author: Maria Yang, MD

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.

Categories
Education

Full Moons and Lunacy.

supermoon

Now that the supermoon has passed, here’s a reminder that there is scant evidence that full moons are associated with erratic, violent, or unusual behavior.

Dr. Chudler offers a brief summary of studies related to human behavior and full moons on his website and notes

Although most experiments fail to show a relationship between the phase of the moon and abnormal behavior, the belief in the “lunar effect” is still strong among many people.

Scientific American also published a piece about this a few years ago and concludes

… the lunar lunacy effect appears to be no better supported than is the idea that the moon is made of green cheese.

Categories
Consult-Liaison Education Medicine Observations Reflection

Pay It Forward.

Prior to starting medical school, I had no desire to work as a psychiatrist. I had a plan: I’d become an infectious disease physician[1. I studied microbiology and molecular genetics in college. My fondness for bacteria persists.] or an oncologist.

During my psychiatry rotation as a medical student I spent four weeks on a consult-liaison service. I worked with an attending who was smart and excellent with patients. Though everyone agreed he wasn’t warm, he was genuinely kind. (He also wore bow ties and suspenders. His clothes never had wrinkles in them. Was this due to his military background?) My plans started to change.[2. It wasn’t a single moment that made me abandon my original intention to go into internal medicine. I still remember the case, though, that tipped me to go into psychiatry: One of my patients on the medicine service was a firefighter who had suffered a significant bleed in his stomach. I was able to talk about the cells and chemistries in his blood, the risk factors that contributed to his condition, and what he could do in the future to prevent this from happening again. Yet, I couldn’t tell anyone anything about him as a person, how he came to have those risk factors, how he perceived those risk factors, and if he had any desire or intentions to change his behaviors so that he could prevent this form happening again.]

Before starting my psychiatry residency, I had no particular interest in working with people experiencing psychotic symptoms (e.g., hearing voices, holding firm beliefs that are not rooted in reality, etc.). I had a plan: I’d become a consult-liaison psychiatrist and spend my days in hospitals spanning the boundary between acute medical care and psychiatry. There was a little of everything in consult-liaison psychiatry: the full spectrum of psychiatric conditions; brief psychotherapy; teaching patients, families, and, often, the staff of the primary medical service; starting and stopping medications to reduce distressing symptoms.

During my residency I found myself finding the most meaning when providing care to people with limited means: refugees from Southeast Asian countries; military veterans with few supports upon their return from wars ranging from World War II to the wars in Iraq and Afghanistan; people living in homeless shelters or on the streets. Medications were not always useful or indicated. The senior residents and attendings in these settings were astute, unpretentious, compassionate, and just good with people. My plans started to change.

Now, as an attending, my interests are a mix of all those things: I like working with people with significant psychiatric symptoms who often have limited means. I like working in teams to help people get better and out of the system, whether that is the hospital, the jail, or the mental health system entirely.

I spent over eight years of medical training under the supervision of “attendings”. It took me a few years to get used to people calling me “Dr. Yang”.[3. I still find it jarring when colleagues who routinely call me “Maria” suddenly address me as “Dr. Yang”.] I guess I’m not yet used to the idea that I am now an attending and people expect me to “know”:

  • a high school student who wants to interview me to ask about my work as a psychiatrist
  • college students who want to learn more about non-traditional work in psychiatry[4. Thanks for helping to inspire this post, Anna!]
  • medical students who want to know which psychiatry residencies they should apply to if they want specific training in working with indigent populations
  • residents who want to know which fellowships they should apply to if they are interested in public sector clinical and administrative duties
  • fellows who want to know where they should apply for work in non-traditional settings

It’s weird. Impostor syndrome persists: These people think I’m qualified to tell them?

When I think about all the people who guided me—intentionally or not—to where I am today, I find that the second best way to thank them is to pay it forward.[5. The first best way to thank people, of course, is to directly thank them for the specific things they said or did.] We need people who have the will and energy to serve the community, who are willing to think about and do things differently. Yes, interests change, plans change, people change. However, we never know how our words and actions may inspire those around us.

Categories
Consult-Liaison Education Informal-curriculum Medicine Nonfiction Observations Reflection

Teaching Moment.

The Chief of Service ushered me into the room, but said nothing. His staff of fifteen looked at the Chief with expectation and, upon realizing that he was looking at me and probably wasn’t go to say anything—including my name or the reason for my visit—the fifteen people joined him in looking at me.

“Hi,” I said, taking the cue and flashing The Winning Smile. This is my name, this is my title, and this is why I’m here: As a psychiatrist, I think there is overlap in the work that we do and in the patients that we see—

“Is it okay if we refer to your patients as ‘wackos’?” the Chief blurted out. Nervous laughter twittered among his staff.

“I’d prefer that you didn’t.” My voice was light; my face was dark.

“Oh. I guess another psychiatrist should have told me that.” He was still smiling.

“I hope I’m not the first one to do so.” When he finally saw the lasers shooting from my eyes, his smile dissolved and he looked down.

There are several reasons why I believe that social skills are not his forte:

  • He either chose not to or did not think he needed to introduce me to his staff.
  • As a Chief of Service he should have known better than to say such things in front of his entire staff.
  • This exchange occurred within five minutes of us meeting each other.

I think his question—“Is it okay if we refer to your patients as ‘wackos’?”—was his honest effort to connect his staff and me together. Everyone would have a good laugh, we’d share something in common, and we could move forward with greater ease. He thought his comment was benign.

It makes me wonder, though: Had he made a similar comment in the past to another psychiatrist? And had that psychiatrist laughed? Did a ridiculous repartee follow?

Did another psychiatrist reinforce this sort of behavior?

He’s not a “schizophrenic”. He’s a guy with a diagnosis of schizophrenia. Maybe he’s even a guy who is skilled guitar player, a father of two children, and has a degree in political science who happens to have a diagnosis of schizophrenia.

She’s not a “brittle diabetic”. She’s a woman with a diagnosis of diabetes. Maybe she has a knack for training dogs, has a remarkable talent for singing, and was on her way to law school when she was first diagnosed with diabetes.

People are people with various interests, talents, and potentials. They are not their medical conditions.

No one is a “wacko”.

The Chief of Service sent me an e-mail later:

Thank you for visiting us and also for your gentle way of reminding me of my crudeness and insensitivity. I am sure you hear enough negative attitudes towards your clients that you would welcome the opportunity to create a more positive attitude towards mental health issues.

I actually don’t hear many “negative attitudes” about my patients. Perhaps this is because every moment can be a teaching moment and, over time, people learn not to use such language (at least around me). As I noted several years ago:

Doc­tors, like most peo­ple, often assign adjec­tives to patients because it can be hard to iden­tify and then acknowl­edge emo­tions. It is much eas­ier to say, “She is such a dif­fi­cult patient! She is never happy with her care!” than to say, “I feel angry and help­less when I see her because it seems like noth­ing improves her symp­toms!” Leav­ing out the sub­jec­tive “I” gives the illu­sion of objec­tiv­ity and professionalism.

I can only hope that the Chief of Service shared his reflection about his “crudeness and insensitivity” with his staff.