Author: Maria Yang, MD

Categories
Nonfiction Observations

Border Crossing.

When we crossed back into the US yesterday, this is how the conversation went with the border officer:

Husband hands officer three US passports.

US BORDER OFFICER: So there’s three of you, huh?

HUSBAND: Yes.

OFFICER: How are the other two connected to you?

HUSBAND: That’s my wife in the back seat and this is her father.

OFFICER: Where do you live?

HUSBAND: Seattle.

OFFICER: Where did you go?

HUSBAND: To Vancouver.

OFFICER: How long were there for?

HUSBAND: Just for the day.

OFFICER: Why did you go to Vancouver?

HUSBAND: To sightsee.

OFFICER: Well, how was it?

PAUSE. HUSBAND and FATHER speak at the same time:

HUSBAND: It was fun.
FATHER: Great!

OFFICER: Are you bringing anything back with you?

HUSBAND: No.

OFFICER: Okay. (hands passports back) Have a nice day.

The car pulls away from checkpoint. MARIA exclaims: That guy was so easy on us! That was the smoothest border crossing we have ever had!

This is the conversation we had the last time we were at the border. I have not embellished it:

Husband hands border officer two passports.

US BORDER OFFICER: How are you two related?

HUSBAND: She’s my wife.

OFFICER: Where do you live?

HUSBAND: Seattle.

OFFICER: Where did you go?

HUSBAND: To Vancouver.

OFFICER: Where did you go in Vancouver?

HUSBAND: Downtown and Stanley Park.

OFFICER: How long were you in Vancouver for?

HUSBAND: Just for the day.

OFFICER: Why were you there just for the day?

HUSBAND: (pointing at MARIA) To see some of her friends.

OFFICER: Why were your friends in Vancouver?

HUSBAND: To take a cruise to Alaska.

OFFICER: Are you bringing anything back with you?

HUSBAND: No.

OFFICER (to HUSBAND): What do you do for a living?

HUSBAND: I’m a scientist.

OFFICER (to MARIA): What do you do for a living?

MARIA: I work as a doctor.

OFFICER: Where did you go to medical school?

MARIA: UC Davis.

OFFICER: Where is UC Davis?

MARIA: Near Sacramento. In California.

OFFICER: Is this your car?

HUSBAND: No, it’s a rental.

OFFICER: If you live in Seattle, why did you rent a car?

HUSBAND: We don’t own a car.

OFFICER flips through passports, scans the faces of HUSBAND and MARIA, then hands them the passports.

OFFICER: Okay. You can go.

Let’s be clear: In the grand scheme of things, this was not a terrible situation. No one asked us to get out of the car. No one searched our bags. No one got hurt.

Most of our experiences at the security checkpoint to return to the US, however, have been more like the second anecdote than the first. The officers often ask irrelevant questions (“what hotel did you stay at?” “what restaurant did you go to?”), make inquiries about the car (“where did you rent the car from?”), and never make pleasantries. In fact, as we were waiting to get to the checkpoint yesterday, we reviewed every single thing we did in Vancouver. We wanted to ensure that we knew all the answers as a group.

Why the difference yesterday? We still used a rental car, everyone in the car still appeared Asian, and we still came from Seattle.

Was it because there were three of us? (Does an algorithm suggest that trios crossing the border are less likely to cause trouble?)

Was it because we had an elder with us? (Does the US border patrol have a lower suspicion of illegal activities when a genial senior citizen is part of the trio?)

Was it because the officer we saw yesterday was in a good mood?

Does it mean anything that Canadian border officers are less intrusive and kinder to us than the US border officers when we are returning home?

Categories
Informal-curriculum Nonfiction Observations

Name-calling.

Let me start by saying that it actually doesn’t happen that often.

The yelling and screaming usually comes from men who aren’t under my care. It often happens when I’m talking with my patients or when I am just walking past a cell block.

Sometimes, it is repetitive yelling that sounds like a metronome:

WHORE! WHORE! WHORE! WHORE!

Sometimes, it is a tirade:

F-CKING SLUT, you’re a F-CKING SLUT, d-mn whore, F-CKING C-NT, YOU HEAR ME? YOU’RE A F-CKING SLUT, YOU F-CKING B-TCH, yes, YOU, you’re a F-CKING BITCH…

Other men take issue with my short hair and assert that I am a lesbian:

You’re a LESBIAN, aren’t you? What the F-CK is wrong with you, LESBO? Why don’t you like dick? F-CKING LESBIAN, you and your F-CKING SHORT HAIR…

For reasons I don’t understand, it is uncommon for men to yell racial slurs at me.[1. No one in jail has yet to call me a “chink“—at least not to my face or when I am in earshot. I did have a patient who would intersperse his sentences with musical phrases: “Ching chong ding ding ting tang…”. He didn’t do this with anyone else. He also refused to believe that I am a physician. He insisted, “There’s no way you’re a doctor. Women can’t be doctors. You’re probably just a clinical assistant. Women aren’t smart enough to be doctors.” I steered the conversation elsewhere.]

I have since learned that those men who yell synonyms for commercial sex workers at me or insist that I am a lesbian become more enraged when I ask them to stop yelling. Usually it goes something like this:

Maria: “Hi. Could you please stop yelling for ten minutes so I can talk to the guy over there? It’s hard for me to hear him.”

Inmate: [spewing more hatred at a louder volume and a greater frequency]

This response differs from other men who yell for different reasons. Often the men who scream about the crimes of the government, the arrival of the aliens, the ghosts in the machines, and the coming of the Antichrist will acknowledge my request and kindly stop yelling. Some can’t stay quiet for more than three minutes, but they try.

On occasion, the men who are my patients—and sometimes these are the same men who proclaim that they are actually machines and not humans, or they can’t string together coherent sentences—will scream past me to the men yelling malicious things: “SHUT THE F-CK UP!”

Their imperatives often go unheeded.

Hearing this vitriol doesn’t bother me too much. I mean, it bothers me enough to write a blog post about it, but such behaviors make me wonder more about the suffering of these men. Perhaps these men are screaming at me because I am on the other side of their cell doors and they feel anger with their lack of freedom. Perhaps these men don’t like the inherent power differential between them and me in a setting like the jail. In an effort to assert dominance a man may shout misogynistic things at me because he is trying to close the gap between his status and my status. Maybe women in his past have done terrible things to him.

My male colleagues have mentioned that these same inmates might insist that they are gay. Otherwise, most of the commentary these men lob against my male colleagues are death threats. This is in contrast to the threats I receive; men usually threaten to rape me. (Let’s be clear: Such threats are rare.) And it is not necessarily the men who scream hateful things at me who threaten rape.

What people say and what they do aren’t always congruent, whether in the jail or elsewhere. Consider the men in jail who have been charged or convicted many times of sexual assault. They may never shout anything at female staff. Some of these men show great courtesy; they look me in the eye; they say “please”, “thank you”, and offer gracious social smiles.

One wonders what they do not say out loud.

Some people will judge you just based on how you look. To some men, women are malignant deviants; they induce fear and loathing. Some men decide that the best course of action is to hurl hatred at women.

Sometimes, they might do even worse things.

Categories
Consult-Liaison Reflection

Questions about the Throwing of Urine.

If a man throws an open container of his own urine at another person, does he have a mental illness?

  • What if he throws an open container of water at another person?
  • What if he throws a closed container of his own urine at another person?

If a man throws an open container of his own urine at a nurse in a hospital, does he have a mental illness?

  • What if he throws his urine at a nurse who is trying to inject him with a medication he doesn’t want?
  • What if he throws his urine at a nurse who is trying to give him food and drink?

If a man throws an open container of his own urine at a nurse on a surgical ward, does he have a mental illness?

  • What if he throws his urine at a nurse while on a psychiatric ward?
  • What if he throws his urine at a nurse while in jail?

If a man throws an open container of his own urine at the police when they charge into his home, does he have a mental illness?

  • What if he throws his urine at the police because he has multiple containers holding his urine and those are the closest things he can grab?
  • What if he throws his urine at the police because he hates the police?
  • What if he throws his urine at the police because he hears voices that tell him to do this to protect himself?

If a man collects his urine into a container over time for the purpose of throwing it at another person, does he have a mental illness?

  • What if he believes his urine is holy water and believes that his urine will baptize others and save their souls?
  • What if he wants to witness the anger and disgust of others when his urine splashes all over their faces?

If a man throws an open container of his own urine at himself, does he have a mental illness?

  • What if he throws his urine on himself because he is in solitary confinement and cannot throw the urine at the person he is angry with?
  • What if he throws his urine on himself because he is in solitary confinement and this is the only way he can have contact with another person?

If a man throws an open container of his own urine at another person, does he have a mental illness? or is he just a jerk?

Categories
Nonfiction Observations

Enclosed.

When the elevator doors slid open, there were twelve men inside the car. Two wore black officer uniforms; the others wore unmarked and faded tops and pants. They all looked at me in silence.

They all saw me hesitate.

“Do you want to get on?” one officer barked. It was a command phrased in the form of a question.

As I took a step forward, one officer stepped out of the elevator. The inmates, wearing not scarlet letters but, instead, red uniforms and cheerless expressions, moved towards the perimeter of the car. The second officer in the elevator took a step backwards, creating a square of space.

I took my assigned spot and the other officer stepped back onto the elevator to close the square. My eyes could only see his folded arms across his broad chest. The light breath of the other officer moved across the back of my neck. The inmates cast their glances—heavy, light, and of all shapes and sizes—at me. I heard my heart beating in my ears.

As the elevator lurched into motion, the air thickened in my chest:

  • If a fight breaks out, I can’t escape.
  • If someone touches me, I won’t know who.
  • If something happens to me right now, who will be more likely to help me…?

The elevator jiggled to a stop and the doors slid open.

“Excuse me.” My voice did not waver, though my confidence did.

Without saying a word the officer stepped out of the elevator. The inmates rearranged themselves in silence. Cool air blew past me as I walked into the elevator bay.

I exhaled.

Categories
Education Medicine Observations Systems

Everything Changes, Nothing Changes.

The Mutter Museum Instagram account recently posted this photo:

Thorazine

“Thorazine” is the trade name for chlorpromazine. It is considered the medication that ushered in the “psychopharmacological revolution”, thus allowing some patients to leave psychiatric institutions. (You can read the interesting history of chlorpromazine here. Spoiler alert: It was designed for use in surgery, not psychiatry.)

Chlorpromazine is often touted as the first medication that could reduce symptoms of schizophrenia. Other FDA-approved “psychiatric” uses of chlorpromazine[1. Other FDA-approved uses of chlorpromazine that are unrelated to psychiatry include acute intermittent porphyria; intractable hiccoughs; nausea and vomiting; and tetanus, “adjunct”.] include:

  • Apprehension, presurgical
  • Bipolar disorder, manic episode
  • Problem behavior, severe

I don’t know the context of the ad (who was the intended audience: physicians? patients? husbands?). One wonders why the ad features a woman and puts greater emphasis on “emotional stress”. A hefty dose of chlorpromazine will result in “prompt” sedation that will give someone—perhaps not the patient—”sustained relief” for several hours.

Did physicians in that era tell patients that the original use of this medication was for schizophrenia? Or did physicians focus primarily on the tranquilizing effects of chlorpromazine for those individuals who had more neurotic, not psychotic, symptoms?

Everything changes, nothing changes. Quetiapine (tradename: Seroquel) was also developed for the treatment of schizophrenia. Now, its uses include:

(1) add-on treatment to an antidepressant for patients with major depressive disorder (MDD) who did not have an adequate response to antidepressant therapy; (2) acute depressive episodes in bipolar disorder; (3) acute manic or mixed episodes in bipolar disorder alone or with lithium or divalproex; (4) long-term treatment of bipolar disorder with lithium or divalproex; and (5) schizophrenia.

The header for the page (what shows up on the browser tab) doesn’t even list the drug’s name. It says only “bipolar disorder medication”.

If you search for “Abilify” (generic name: aripiprazole) on Google, the brief summary that shows up under the first link says:

Official pharmaceutical site for this antipsychotic medication indicated for the treatment of schizophrenia.

However, when you actually go to the official website, the listed uses include:

Use as an add-on treatment for adults with depression when an antidepressant alone is not enough
Treatment of manic or mixed episodes associated with bipolar I disorder in adults and in pediatric patients 10 to 17 years of age
Treatment of schizophrenia in adults and in adolescents 13 to 17 years of age
Treatment of irritability associated with autistic disorder in pediatric patients 6 to 17 years of age

Asenapine (trade name: Saphris) also has approval to treat both schizophrenia and bipolar disorder. Should we be surprised if paliperidone (trade name: Invega[2. Does it mean anything that, of the five photos on the landing page for paliperidone, only one of them features white males?]) and iloperidone (trade name: Fanapt) soon also receive FDA approval to treat conditions other than schizophrenia?

This is why skepticism is indicated—nay, essential—whenever people exclaim with confidence that “we” understand the biology of psychiatric conditions. We live in an era where cancer drugs can be designed to interact with specific receptors because scientists have located and studied those specific receptors. That specificity does not exist in psychiatry. If it did, one drug class would treat one condition, not four.

While I am probably more reluctant than the “average” psychiatrist to prescribe medications, I believe that, for some people with significant psychiatric conditions, medications can offer great benefit. First, however, do no harm.

It is frustrating when many in the field of psychiatry insist that the serotonin hypothesis is true when, in fact, it is just a hypothesis that is probably false. Also frustrating are the multiple forces that insist that medications are the primary and sole forms of treatment for psychiatric conditions. What about exercise? Therapy? Diet? Social support?

If medications alone could successfully treat these conditions, wouldn’t the pharmaceutical companies have saved us all by now?