Author: Maria Yang, MD

Categories
Blogosphere Medicine Observations Policy Systems

Why I Work at the Fringe.

This article is making the rounds among physicians on Twitter. Much of the information in the article, unfortunately, is accurate.

For some of the reasons stated there, I left the “traditional” health care system and pursued work at the “fringe”.

Part of this is due to my clinical interests: I like working at the intersections of different fields. For example, I like the intersection of psychiatry and hospital medicine, which is called psychosomatic medicine. Another example is my interest in public psychiatry, which focuses on the intersection of social factors and mental health (e.g., individuals with psychiatric and substance use conditions in the context of homelessness and poverty).[1. Really, though, all of medicine could be “psychosomatic medicine” or “public psychiatry”; the divisions between mind, body, and environment are arbitrary.]

Part of this, though, was my sense that the system would not let me be the kind of doctor I want to be.

For a brief period I worked in a clinic where I had slots for four new intakes a day (60 minutes each) and 15-minute follow-up appointments for the rest of the day. If my schedule was completely filled with follow-up appointments, I could have seen up to 34 patients a day. (I never got to this point because I quit well before my panel got full.)

In reality, the 15-minute appointments were 12-minute appointments. I needed about three minutes to type out some notes to myself for clinical documentation.[2. I don’t like typing my note while I am seeing a patient. I’m not fully attending to either one when I do that.]

Because I was building a new practice, people with a wide variety of conditions and concerns came to see me. I was advised to refer patients out of the medical center who were “too sick”. This included individuals who were frequently in and out of psychiatric hospitals, had significant psychiatric symptoms, or otherwise had other stressors in their lives that made them “difficult“.

In other words, they told me to refer out the people who needed specialist care the most.

The reality, too, was that no psychiatrist could provide quality care to these individuals in 12 minutes. Imagine someone with depression so severe that he lacks the energy or interest to share his current distress with you. Or someone who is psychotic and insists that her ex-husband is tracking her through all the electronics in her home. Or someone who is so anxious about leaving his house that his attendance to the clinic is worthy of celebration.

Obtaining an accurate history guides diagnosis, which then guides treatment. An insufficient history can thus lead to haphazard interventions. You can see how the 15-minute appointment model results in heavy reliance upon (potentially unnecessary) medications. If someone says he feels depressed, it’s difficult to validate his emotional experience, provide education about his condition and non-pharmacological ways to manage it (e.g., behavioral activation, sleep hygiene, etc.), and have a discussion about medications, which should always include risks, benefits, and alternatives, in 12 minutes.

It is much easier to write a script and ask someone to return in a month. (This inspired my post about the Automated Psychiatrist Machine.)

Furthermore, this clinic was in a medical center with a group of primary care physicians. Primary care doctors referred their patients with diagnoses of schizophrenia and bipolar disorder to the psychiatry clinic (as they should). These individuals, however, were “too sick”. Never mind that, unlike the primary care physicians, we psychiatrists had the training to diagnose, treat, and manage these individuals with significant psychiatric conditions.

Thus, these patients often returned to their poor primary care physicians, who tried to care for them the best they could… which often entailed medication regimens that were unnecessary. (Primary care physicians deserve no blame for this: How are they supposed to know?)

This clinic also “rewarded” psychiatrists for “productivity”. The more patients a psychiatrist saw, the more money the psychiatrist would earn. This led to “cherry-picking” patients. Psychiatrists would keep patients who either had minor conditions or symptoms that had resolved, because those are the patients you can adequately see in 12 minutes. As a consequence, patients with more debilitating symptoms could not access the clinic. The psychiatrists had no incentives in either time or money to send these “cherry-picked” patients back to their primary care doctors.

My frustration and disillusionment compelled me to leave the job. I returned to positions at the “fringe” to work with patients who often are also not part of the system or patients that the system had failed. Consider the man who has been homeless for the past ten years and is too paranoid to access any health care service. Or the woman who was beaten and molested as a child, sent to foster care and group homes, never completed high school, “aged out” of youth care, and now has no resources or support.

I couldn’t wait for the system to change, so I sought out settings where both my skills would be useful and I could be the kind of doctor I want to be. There may not be many physician jobs at the “fringe” and certainly not all physicians want to work there. When we physicians vote with our feet, though, we show what we value, the kind of care patients deserve, and how the system must change.

Categories
Consult-Liaison Education Medicine Reading

DSM-5: Malingering.

My DSM-5 group has lost its previous vitality for the same reasons my blog has lost its previous verve (pending job change, ongoing family health concerns). But! The DSM-5 group has had a few updates; the most recent edition is below. If you’re interested in subscribing to the DSM-5 e-mail group, you can sign up here.

Malingering in DSM-5, like in DSM-IV, is a “V code”. “V codes” (in ICD-9) will turn into “Z codes” (in ICD-10) and these are considered “other conditions that may be a focus on clinical attention”. This means two things:

(1) Conditions listed as “V codes” are not diagnoses because

(2) Conditions listed as “V codes” are not mental disorders.

Therefore, malingering is not a mental disorder.

In crass terms, malingering means that people are faking or *really* embellishing physical or psychological symptoms. People who are malingering do this “consciously” (hat tip to the analysts) because there is an external incentive to do so. These external incentives might include:

a) avoiding military duty
b) avoiding work
c) obtaining financial compensation
d) evading criminal prosecution
e) obtaining drugs

Malingering can be hugely adaptive: If you were homeless and the temperatures outside are below freezing and a winter wind is whipping the frost off of the trees and there are no open shelter beds and you are hungry because the last time you ate was two days ago and that was a soggy, half-eaten sandwich you found in the trashcan–

–wouldn’t you consider going to the hospital and say that you want to kill yourself so you could be in a warm place for a few hours and get some non-soggy food?

DSM-5 argues that if “any combination” of the following four items is present in a patient, you should consider the condition of malingering:

(1) Medicolegal context of presentation (a lawyer sends the client for evaluation or the patient presents for care in the midst of criminal charges)

(2) There is a “marked discrepancy” between the individual’s “claimed stress or disability” and “objective findings and observations”

(3) “Lack of cooperation during the diagnostic evaluation and in complying with the prescribed treatment regimen” (some tired clinicians would summarize this as “a difficult patient”, though I much prefer DSM-5’s description)

(4) The presence of antisocial personality disorder

I applaud DSM-5’s efforts in keeping the description of malingering neutral. Some people have strong reactions towards (translation: self-righteous fury at) people who present with malingering. Keeping the focus on the behaviors helps temper the emotional reactions.

DSM-5 then clarifies the differences between malingering and factitious disorder, conversion disorder, and related conditions. Malingering is the only condition here where symptoms appear solely because there is an external incentive.

On a somewhat related note, the condition that follows malingering in DSM-5 is “wandering associated with a mental disorder”. This is apparently limited to walking (where the “desire to walk about leads to significant clinical management or safety concerns”).

The next post will hopefully show up less than one month away.

Categories
Homelessness Observations

All Four Seasons.

Green leaves are budding from the trees lining the city streets. The branches sway from the weight of small birds, their throats full of song. The chill in the morning air melts away as the Spring sun warms the ground, beckoning the flowers to push through the damp earth. Pedestrians carry their umbrellas and weave around the puddles on the sidewalk.

Some of them do not see the soiled sneakers poking out from under the bundle of blankets heaped in the shop doorway. Some people cast a sideways glance and say nothing. They have places to go.

People turn the calendar pages and begin to wear white again as Summer breezes into the city. The air is thick with moisture and the asphalt radiates the heat of the sun. When shop doors open and the cool conditioned air whooshes outside, people wearing strappy sandals, twill shorts, and thin tank tops sigh with relief. Fireworks light up the sky, people have picnics in the park, and the kids catch fireflies at night.

The bundles of blankets have moved underneath the bridges and along the banks of the river. The shop owners, taking advantage of the longer hours of the season, throw away the flattened cardboard boxes they find near their doorways. These are entryways, not platforms for beds.

The arc of the sun shortens and fog begins to drift into the city. The once verdant trees now don red, orange, and yellow leaves. The Autumn rain begins to fall. Kids pile into school buses and adults board the train, all daydreaming about their summer adventures.

The bundle of blankets appear downtown again. The blankets get wet from the frost in the woods. Rectangles of cardboard, piles of blankets, and rolling suitcases collect under the awnings of buildings.

Old man Winter hobbles into town. Freezing rain and snow fall from the pewter sky. People hurry to the store to stock up on toilet paper, bread, milk, and canned food. Their breath turns to white mist as they mutter about the cold and prepare for several feet of snow. Smoke floats out of chimneys, readers snuggle with books, and the kettles whistle when the water boils.

The bundles of blankets poke out of cardboard forts dressed with tarps or garbage bags. The snow is already collecting on the corrugated roofs, which sag from the wet weight.

“If you see someone in need during the storm,” the newscasters say, “if you see someone who is homeless, call this phone number.”

The homeless are there all the time. They are there all four seasons.

Categories
Blogosphere Medicine Observations

Fear and the Online Physician.

To follow up on my last post I had intended to write something that follows the style of an FAQ:

  • What if your patients read your blog?
  • What if your boss reads your blog?
  • What if your patients ask you for medical advice through your blog?

Fear underlies all of those questions, though, and it seemed to make more sense to address that fear.

If you are a physician and you are concerned about the vulnerability of having an online presence, what do you worry about? Do you worry that patients will learn to hate you? That your boss will find a reason to fire you? That random patients will “bother” you?[1. Why do some physicians worry that patients will find them online and “bother” them? What low opinions we must have of patients if we automatically assume that they will “bother” us! And what little faith we must have in ourselves to establish and maintain boundaries should that happen! And how grandiose we must be to believe that patients want to expend the time and energy to “bother” us!]

Would you do something on the internet that you wouldn’t do “in real life” as a physician?

All the people you interact with as a physician—your patients, your colleagues, that person who works in the system, but you see him only every few months—already have opinions about you. You build your reputation with the little things you do every day.

If you think patients are lazy, your behavior will reveal that belief. If you tell someone (a colleague! a friend! another patient!) that you think patients are lazy, that will eventually become common knowledge. If someone confronts you about that, you’ll manage it the way you manage it… and people will observe that, too.

Recording your belief on the internet that patients are lazy seems like a bad idea (because it is). Stuff stays online for a long time and people will find it. If that scares you, it should. But if you’re not doing things like that “in real life” now, why would you suddenly start doing that on the internet?

You might think that the lack of an online presence (or having an anonymous presence[2. It may be true that physicians, under cloaks of ostensible anonymity, can report and discuss problems in medicine with greater candor. Whistle-blowing can be a good and necessary thing. However, anonymity is ultimately short-sighted: It is difficult to maintain true anonymity on the internet. More importantly, if people know who you are, you have greater power and credibility to identify and solve problems.]) will protect you because if they can’t find you, they won’t talk about who you are, what you think, and what you do.

That’s not true. People already talk about you.[3. Yes, people are talking about you, but let’s be realistic: They don’t talk about you all the time. Or even all that often.]

And these are people who know what you look like, know where you work, and have experience interacting with you. Patients who don’t like you will continue to dislike you. They’ve probably told someone why they don’t like you. Who knows: They might’ve even shared their opinions about you on the internet. (As I have noted elsewhere: Having an online presence gives you the opportunity to shape your reputation on the internet. You already take active steps to shape your reputation “in real life”: Maybe you make a point of greeting everyone at work with a smile. Or overtly washing your hands in front of patients.)

The internet may be different medium, but the messages we send are the same. It’s also a place to learn and exchange ideas: What are other medical professionals learning? What do patients want? What problems are we trying to solve? How can we make things better? We’d like you to join the conversation.

As a physician you’re trained to discuss risks, benefits, and alternatives about interventions with patients. Having a presence online has its own risks and benefits. If you do decide to step into the online arena, know that you aren’t alone: There are many physicians who write on the internet. Join us.

Categories
Blogosphere Nonfiction Reflection

My Brief History on the Internet.

The first time I posted my writing on the internet was in 1997. I created a website about The Evolution of Mickey Mouse. It was based on a report I wrote in high school about the small mammal. My research for this report entailed several visits to the library to scroll through multiple rolls of microfilm (do kids these days even know what microfilm is?) to find articles that described the mouse during his heyday. I decided to put my findings on the internet so other people wouldn’t have to dig through canisters of microfilm. That Mickey Mouse website did well: For a short period of time, back when the Yahoo! search engine reigned supreme and Google was new, the site was ranked #2 with the search terms “Mickey Mouse”.[1. Disney.com, of course, came up first if you searched for “Mickey Mouse”.] Children from the world over sent me e-mails with instructions to “say hi” to Mickey Mouse. The internet was a sweet and innocent place.

My first blog was hosted on Open Diary. It was late 2000 and I was a medical student. I used a nom de plume that now causes me some mild embarrassment. I wanted to record my experiences in medical training. This was not a new practice for me: In junior high, high school, and college, I filled the college-ruled pages of dozens of spiral-bound notebooks with my thoughts. To my knowledge, there weren’t many medical students blogging at that time. Other Open Diary users read my writing, seemed to enjoy it, and expressed interest in what happens in medical school. Writing for an audience was fun. The internet was a social and friendly place.

Open Diary used fixed templates. While I knew that the substance of the writing was paramount, I wanted more style on the screen. That’s when I moved my writing to Blogger (still owned by Pyra Labs at that time) and adopted the title “intueri: to contemplate”. That would remain the name of my blog for six to seven years. I dropped my nom de plume and started using my first name. No one could figure out who I am with just my first name, right? And even if they do, who’s gonna care?

I wrote about my experiences in medical school… and then about my experiences in residency. My blog moved off of Blogger and I bought my own domain. I used MovableType for a few years. I then tried WordPress and have used it since. I read Instapundit and he posted an e-mail I sent to him. Ezra Klein, before he became Ezra Klein, called me “one of the web’s most graceful prose stylists“. I hosted Grand Rounds a few times.[2. If you know what Grand Rounds is, that shows your blogging age.] I started meeting people who read my writing online. The internet was a dynamic and exciting place.

I started feeling ambivalent about writing online. I closed down comments because anonymous people left statements like, “ALL PSYCHIATRISTS SHOULD DIE” and “YOU’RE A PSYCHIATRIST, YOU KILL CHILDREN”. A physician who wrote a blog under a pseudonym was revealed in court. I worried that my writing wasn’t fictitious enough, that maybe my stories weren’t purely coincidental. My mind generated catastrophes: Someone might read a story and think I was talking about them! They would sue me and I would lose my license! Other doctors would judge me! I would never recover! Even if I did, one of those commenters who hate psychiatrists would then kill me!

So I shut down that blog. The internet was a scary and dangerous place.

I moved to New York City. A man who was living there had been reading my blog for a few years. He suggested that we meet. We dated. We eventually got married in Central Park.

I couldn’t not write. Nearly two years had passed since I had posted any of my writing online. I decided to start another blog, though I did not want to write in fear. In White Ink revealed my full name. (Nothing bad happened.) The first post appeared there in 2010. The internet was not dangerous place, though not an innocent place, either. The internet was a place to learn.

I purchased this domain name, mariayang.org, that same year. Would you believe that it took nearly four years for me to build the courage to finally occupy the space?

Next time: Occasionally asked questions about blogging as a physician.