Author: Maria Yang, MD

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Medicine Nonfiction Observations Seattle Systems

On What Medical Directors “Should” Look Like.

I recently answered a survey about race. One question asked:

“If you ask to speak to the leader of your organization, can you expect to see someone of your race?”

I snorted. I didn’t mean to. I just had never thought about that before.

In my previous job my title[1. As I have noted elsewhere, “titles, at the end of the day, are just words.“] was “medical director”. During the first few months of that job the title felt alien to me. It was as if people at work said, “Oh, Dr. Yang? She’s the one over there with the blonde hair.” Meanwhile, I’d touch my black locks, feeling perplexed.

Early on I conducted interviews to hire staff. One applicant, a psychiatrist, was a Caucasian man in his early 50s. His greying brown hair was cropped close to his head. A striped burgundy necktie adorned the light blue dress shirt underneath his navy blue suit. Cuff links poked out from under his sleeves. A silver pen was clipped into the breast pocket of his jacket.

Turning to the program manager, I murmured, “THAT guy looks like a medical director, not me!”

She, a Caucasian woman, laughed before she said, “Yeah, you’re right!”

In the jobs I’ve held the medical directors have all been Caucasian males, with the exception of my first job: He was Asian. In residency training the chair of the department was a Caucasian male. The paintings and photographs of leadership that lined the halls of the medical school were all of aging Caucasian men.

That’s how I came to learn that medical directors don’t look like me; they’re older white men.

Leadership at this agency believed I had sufficient qualifications and hired me, an Asian female, to serve as the medical director. However, the idea that someone in this position “should” be an older white male persisted in my mind.

What does it mean that I felt doubts about my ability to work as a medical director simply because of the way I look?[2. While this post is focused on race, it could easily focus on sex, too: Most medical directors are men.]

Categories
Nonfiction Observations Reflection

Baseball Rituals.

Prior to attending a minor league baseball game recently, I learned about racing events that occur at certain ballparks:

“Baseball is so schlocky,” I said after viewing a YouTube video of the Presidents with their oversized heads teetering along the perimeter of the field. “No other professional sport has anything like this.”

“That’s not true,” my husband replied. “They throw octopuses onto the ice in hockey.”

After learning that, indeed, there is a Legend of the Octopus, I still expressed skepticism: “Could you imagine a whole bunch of sausages running around on a football field?”

“Football has cheerleaders,” my husband retorted.

Good point.

The mascot was busy at the minor league baseball game. Not only did Rhubarb the Reindeer hustle around the stadium with a flag at the start of the game, but he also came out in boxing regalia at one point and, later, wearing a dress shirt and slacks, “performed” a Talking Heads song.

A few rows behind us a man with a voice rattling with gravel shouted at the players:

This is baseball, not first base ball!
Communicate!
Boring!

His son started shouting similar things at the players. When we turned around to see who they were, we realized that the higher pitched voice did not come from his son; it came from his wife.

When the 7th inning came around, we all stood up and sang “Take Me Out to the Ballgame” in different keys. I then ate some Cracker Jack.

I wondered if all this schlock these rituals are meant to appease our short attention spans. Ball 1, ball 2, strike 1… the man with the gravel in his throat shouts unsolicited advice, people get up to buy hot dogs and beer, the bugle calls “Charge!” It’s hard to wait. We want stuff to happen.

Then I wondered if these rituals give us simple comfort while everything else changes. Even if my boss doesn’t give me enough time or credit for the work I do or my wife is angry at me for reasons I think are ridiculous or my kid is not meeting my academic expectations or my friends are worried I have a drinking problem or my boyfriend has hit me twice this week or I lost all of my savings at the casino or my sister died in a car crash last month…

… at least I know that I can caterwaul “Take Me Out to the Ballgame” in the 7th inning, Rhubarb the Reindeer will dance on top of the dugout, and the pierogies will race.

Categories
Homelessness Nonfiction Observations Seattle

Simple Pleasures.

People hung hammocks between trees and suspended their disbelief in novels. Cyclists rolled past, talking to each other over their shoulders. Parents pushed sleeping babies in strollers while sipping iced coffees and slushies. Couples held hands and shielded their eyes from the afternoon sun. It tossed silver glitter onto the blue water of the bay.

Not a cloud was in the sky: Mt. Rainier loomed white and massive to the south. The Olympic Mountains, also capped with snow, rose in the west, its jagged ridges carving a grey-blue line on the horizon. Trees full of green leaves covered the islands in the distance.

The man was wearing baggy pants and dirty work boots. Over this was an oversized and puffy winter parka, tattered at the edges and the hood pulled over his head. A duffel bag that was half his size hung from his left shoulder; as he walked he listed to the right to maintain his balance. People gave him wide berth as they walked past him. He held his head low.

He dropped his bag on the boardwalk and sat down. Sitting against a post, his back to the brilliant sun and shimmering water, he zipped open the duffel. From it he pulled a brown paper sack. He used one hand to rustle through the contents within.

He pulled out a small item wrapped in white. With expectation on his face he opened the package. Leaning back, he took a bite from the chocolate-covered ice cream bar. A small smile crossed his lips.

Categories
Consult-Liaison Education Medicine Observations Policy Systems

Buprenorphine and Other Controlled Substances.

I recently completed the buprenorphine waiver training. Buprenorphine, itself a partial opiate, is a medication that can be prescribed to patients who have opiate use disorders (e.g., taking Oxycontins or injecting heroin to get high). A physician must complete an eight-hour training and take an exam to become eligible to prescribe this medication. The physician must then apply for a specific “X license” through the DEA to prescribe it.

In some ways treatment of substance use disorders is the most evidence-based practice in psychiatry. When talking about opiate use disorders, for example, we can talk about specific mu-opioid receptors and their roles in pain and intoxication. We can discuss how drugs—both illicit and licit—work on these receptors and why certain medications can reduce or eliminate illegal drug use. This logic satisfies the analytical mind.

Since completing this training I have wondered: Why must one undergo a specific training and obtain a separate DEA license to prescribe buprenorphine?

With my current licenses I could prescribe all forms of pharmaceutical morphine (e.g., Oxycontin and Dilaudid), which can lead to severe physical and psychological dependence. Which could then result in the intervention of buprenorphine.

As a psychiatrist I would likely arouse the suspicions of the DEA if I prescribed opiate medications. That’s outside the scope of a psychiatrist’s practice.

However, it is not outside of the scope of a psychiatrist’s practice to prescribe benzodiazepines (e.g., Valium and Xanax), which are Schedule IV drugs (“a low potential for abuse relative to substances in Schedule III”).[1. You can learn more about controlled drug “schedules” on the DEA website.] I can also prescribe Schedule II drugs (“high potential for abuse which may lead to severe psychological or physical dependence”), such as Adderall and Ritalin. Physicians are not required to go through any special training or obtain separate licenses to prescribe those medications. Once I got my DEA license, I was free to prescribe these without anyone looking at me askance.

And, get this: buprenorphine is a schedule III drug!

The training offered the Harrison Narcotics Tax Act of 1914 as one reason behind the training requirement: This law suggests physicians can prescribe opiates as part of “normal” treatment, but not for treatment for addiction. Addiction was not considered a disease in 1914. Thus, if addiction is not a disease, no intervention is indicated.

That explanation, however, doesn’t make sense. There is growing consensus that substance use disorders are diseases. Nothing, other than my good judgment, prevents me from cranking out prescriptions for stimulants and benzodiazepines. Use of either medication can lead to addiction. What makes opiates so special?

The consequences of the buprenorphine training are not slight: The eight-hour training alone likely deters some physicians from pursuing it. The extra licensure is also an obstacle, as well as the consequences of using the license: No one wants regular, but unannounced, DEA audits (which, just to be clear, doesn’t happen with when one prescribes benzodiazepines or stimulants). No one is eager to maintain the documentation that is required when one prescribes buprenorphine.

It just makes me wonder what the actual story is….

Categories
Nonfiction Observations Reflection

Grief.

Shortly after my mother died, a coworker asked me about grief: “What does it feel like?”

I remember looking at her and feeling confused. What does it feel like…?

Words like “terrible”, “awful”, “really sad”, and “numb” didn’t seem quite right. Elements of all those adjectives were true, but none of them captured the fine texture of grief.

“It feels like… a really bad breakup,” I finally said. As the words came out of my mouth I realized that wasn’t quite right. It was also an inane comparison.

“Huh,” she answered.

Nine months later, I found words to describe my grief: It feels like my heart is falling.

During moments of stillness, those spaces between exhalations and inhalations, I feel my heart physically dropping. It is an endless fall; there is no bottom.

I remain surprised with how close to the surface the grief lives. I don’t cry when I talk about my mother’s death. Yet, when people ask me about her, I feel my face scrunching up the way faces do when people are about to cry. The sensations in my face remind me of that week she was in the hospital, when I smiled during the day and wept at night, asking God and the Universe questions that nobody could answer.

Though the tears do not come, my face suggests they will. And I know that the person listening to me sees it. It’s like when you blush: You feel your cheeks flash with heat and hope that the other person won’t make fun of you for it.

Emotions always shift, though: Sometimes, in my mind’s eye, I set an imaginary table and place a pot of steaming tea and two cups on it. I invite Grief to sit down and have tea with me. Grief never declines. I ask Grief how it is doing. Grief never says anything in response, but we sit in silence and enjoy our tea together. When Grief is ready, it leaves.

And then I notice that my heart is no longer falling.

Almost 11 months have passed since my mother died. Since I found words for my grief, my heart doesn’t feel like it is dropping as often. Maybe the time I needed has elapsed; maybe the sensation of my heart falling doesn’t overwhelm me as much as it used to.

Maybe by showing Grief some kindness and acceptance with imaginary tea it has also shown kindness to me.