Categories
Observations Reading

Book Recommendations.

In an effort to post more often (and why not start on the first day of the year?), allow me to recommend some books. I read these books in 2012. You may wish to read them in 2013.

The Three Christs of Ypsilanti (Rokeach)
This non-fiction book describes a research study a psychologist conducted at Ypsilanti State Hospital during the 1960s. Three male patients each believe that he is Jesus Christ. The psychologist asks the three men to meet with each other regularly. He wonders if the constant confrontations of identity will resolve their delusions. The book chronicles these meetings and the outcomes.

Readers also learn about psychiatric institutions, wonder if the three men would be sent to an institution in modern times (I suspect not), and consider the ethics of psychiatric treatment, both then and now.

Thinking in Systems: A Primer (Meadows)
This non-fiction book describes the components and behaviors of systems. It may not sound interesting, but examples from the book may reveal the reader’s tendencies to look at events from the point of view of an individual. For readers who already view events from systems’ aspect, the book reinforces that perspective.

It is easy to blame individuals for problems, both in our personal lives and across society. For those of us who believe that people do their best under any given circumstances, viewing problems from a systems’ perspective helps us improve those circumstances. Individual people will then hopefully experience less blame and stress. Thinking in systems cultivates a holistic viewpoint, which builds community and helps us work together towards desired outcomes—and not just outcomes related to productivity and cost savings.

Nothing to Envy: Ordinary Lives in North Korea (Demick)
This non-fiction book[1. I do occasionally read fiction, though after reading Harry Potter (in 2012—I’m not exactly fashionably late), I apparently had to take a break. I read The DaVinci Code in 2012… and you will notice that it is not on this list.] follows the lives of several people living in North Korea. The author does an excellent job reminding readers of the freedoms and wealth we have in democratic countries. The book is disturbing, sad, and informative.

Morita Therapy and the True Nature of Anxiety-Based Disorders: Shinkeishitsu (Morita)
Much of my training as a psychiatrist was based on ideas of mind from Western thinkers. Morita Therapy was developed by a physician in Japan. As with other Eastern-influenced therapies, Morita therapy focuses on the practice of acceptance of self and “reality”. There is also a strong focus on behavioral interventions. Morita and Freud lived around the same time and the contrast in philosophies is interesting (e.g. there is no mention of penis envy in Morita’s text).

If you have any book recommendations for me, let me know on Twitter or Facebook.


Categories
Lessons Medicine Nonfiction NYC Observations Seattle

Doctor as Patient.

It had been about two years since I last saw a primary care doctor. I was still living in New York City. My initial—and only—appointment with that physician lasted nearly an hour.

The front desk clerk had a round, pale face. Behind her was a textured wall over which ran a thin sheet of quiet water. Lush leaves spilled over the brim of the planter onto the marbled countertop.

“I’ll let the doctor know you’re here,” she nearly whispered.

He was a family practice physician. He was friendly. He smiled at me. He asked me if I lived in the city. When he learned that I worked as a psychiatrist, he commented, “Wow. That’s hard work, Dr. Yang.”

It was professional courtesy to address me by that title, though it didn’t feel right to me. I looked down to mask my discomfort. My feet dangled off of the examination table.

“Do you have a private practice?”

No, I said. I worked primarily with people who were homeless.

“Oh,” he said. “That’s even harder work.”

He asked me about my medical history, then my family history. He went through the major components of a physical exam.

He told me about his work as a primary care doctor. As a physician in primary care, it was getting more difficult to stay in business. He previously worked in New Jersey, but had been practicing in New York for a few years. He didn’t think he would leave the city. He was established now.

His technician then put square stickers on my chest and the EKG machine printed out my heart rhythms. Next, I took a deep breath in and held it as another technician took a chest X-ray. And then, another technician, who apparently worked as an anesthesiologist when he was living in his native country, told me not to worry too much when he drew my blood.

“It won’t hurt at all,” he snickered.

The physician called me two weeks later. He said that everything looked fine.


My primary care appointment in Seattle was one of the first visits of the physician’s day. I walked into the medical center and looked at the directory. I must have looked perplexed. A portly man with glasses asked, “Can I help you find something?”

“I’m looking for Dr. X’s office.”

“Fifth floor.”

Dr. X wasn’t a physician in private practice. Are there even family practice doctors in private practice in Seattle? I wasn’t sure how long the appointment would be. Not long ago, I was working with primary care physicians who had appointment lengths of 20 minutes. I envied them. I only had 15 minutes with each patient. A lot could happen in those extra five minutes.

The medical assistant was wearing a plaid shirt and black high-top sneakers. I couldn’t help but think that no medical assistant would dare wear anything like that in New York.

He left me alone in the exam room and I waited. It was a cold room and the gown was thin. I hoped that my doctor wouldn’t be harried and rushed.

After the physician knocked on the door, she quickly entered and gently shut the door behind her. She was about my age. She wore a long white coat and her stethoscope was around her neck. I immediately thought of the snarky comment one of the surgery residents had made about internists when I was a medical student:

“They wear their stethoscopes like they’re dog collars.”

“Hello, Ms. Yang—Dr. Yang? Dr. Yang, right?”

“Yes,” I said. There was that professional courtesy again.

She didn’t ask me many questions. I had filled out the general health questionnaire prior to the visit; she reviewed my responses. She typed some notes on the computer while we talked.

With what seemed like some sheepishness, she provided counsel on vitamin D. Maybe she thought that I was already aware of this. Maybe she thought that she shouldn’t go on about it because I had resources to look it up myself. Maybe she didn’t want to seem condescending. I couldn’t help but think, Don’t worry about me—just do your job. I don’t follow vitamin D as closely as you do, just as you don’t follow schizophrenia as closely as I do.

She went through the major components of a physical exam. We soon were talking about her job.

“Yeah, I went to a Prestigious Residency, but it really was malignant,” she said, pushing on my abdomen. “I’m so glad that I have this job here.”

“Do you mind if I ask about any productivity requirements you might have?”

“You may not believe this, but my schedule is built so that I only have seven patients scheduled in the morning and seven in the afternoon. I can add more on, but that’s the general schedule. That gives me time to call patients, return e-mails, and spend more time with geriatric patients, since, you know, they often have a lot of health problems and need more time.”

I was silently doing the math in my head. Seven patients for an entire morning! There were days when I had seven patients scheduled in two hours!

“Yeah, I can’t imagine working like that,” she said.

She spoke quickly after she completed the exam. “If you have any questions, you can call me or send a message through the website. It was nice to meet you.”

As I was getting dressed, I found myself wondering about all the tests she could have done, but did not. Wouldn’t it have been nice if she had baseline studies for me? What if I developed an arrhythmia in the future? Wouldn’t a previous EKG be useful for that? And what about basic labs? What if my kidneys start to peter out? Wouldn’t it be nice to know that they were fine in 2012?

And then I caught myself. Most women my age are healthy and without medical problems. I hadn’t endorsed any symptoms that would warrant further intervention. Tests had their risks, too.

Doctor as patient. I considered myself lucky that I was able to leave without new diagnoses or the need to return within a few weeks.

And I remembered again what it was like to be a patient.

Categories
Education Lessons Medicine Nonfiction Observations

An Open Letter to All the Patients I Have Ever Cared For.

Originally written during my second year of residency. Now that I am an attending, I believe more than ever that patients “are our best and most effective teachers”.


Dear Patient(s),

Thank you for educating me.

Thank you for letting me shine bright lights into your eyes and place Q-tips up your nose. Thank you for not shooting me a dirty look when I ask you to lift up your pendulous breast so I can listen to your heart. Thank you for letting me ogle at your protuberant belly—whether it contains a baby, a liver tumor, or liters of fluid inside. Thank you for not experiencing an erection and for refraining from snide remarks when I examine your penis. Thank you for telling me that my speculum use is suboptimal and has caused you pain during your pelvic exam. Thank you for nearly kicking me in the face when I tap on your knees to test your reflexes. Thank you for peeing all over me after I remove your diaper.

Thank you for answering questions that, in any other context, are completely obnoxious and rude. Thank you for being honest with me when I ask if you are a prostitute, an IV drug user, or an alcoholic. Thank you for not assaulting me when I ask if you have sex with “men, women, or both”. Thank you for answering questions about hearing loss when you’re actually concerned about your chest pain. Thank you for not yelling at me in impatience when your back pain is “a ten out of ten”.

Thank you for telling me that it doesn’t seem like I am taking that symptom seriously. Thank you for not masking your facial expressions and allowing your face to contort in offense when I phrase a question or statement poorly. Thank you for saying “OW” when I do something that causes you pain. Thank you for screaming in my face for the duration of our time together after I look into your ears.

Thank you for letting me wake you up at 4:30am for the sole purpose of allowing me to examine your belly wound. Thank you for letting me wake you up at 8:30am, a mere ten minutes after you fell asleep after being up all night and writhing in agony in the ER. Thank you for asking me if I could get your a cup of water or ice chips. Thank you for reminding me that your thirst matters more to you right now than the fact that your potassium level is uncomfortably low.

Thank you for apologizing when you throw up all over yourself—not that you should, but your mindfulness in that moment illuminates a strength that you have that I don’t know that I would have in that moment. Thank you for crying in front of me. Thank you for sharing your deepest fears with me. Thank you for asking me to leave so you can spend time with your family, all of whom are devastated with your prognosis. Thank you for asking me to sit with you. Thank you for asking me to listen. Thank you for reminding me that sometimes, being present with patients is more important than writing for another antibiotic.

Thank you for answering questions that you have already answered for five other people. Thank you for not yelling at me when I ask the same question twice in the same interview. Thank you for refraining from comments like “You’re totally imcompetent” when attending physicians have brought up a diagnostic or therapeutic possibility that I had completely overlooked (or just did not know). Thank you for not spitting in my face when all I seem to say is “I don’t know”. Thank you for not throwing things at me while I nod off when the attending physician is speaking to you.

Thank you for telling me that you have thought about killing another person. Thank you for your attempts at pushing my buttons, whether it be through questioning my technical knowledge, academic status, or medical specialty. Thank you for sneering at me.

Thank you for calling me “doctor” when I don’t feel like one at all. Thank you for saying “thank you” when you’re getting better—in spite of me, not because of me. Thank you for poking fun at me for the express purpose of making me laugh. Thank you for giving me a hug before you leave the hospital. Thank you for smiling at me.

Medical school and residency training involves a lot of reading, tests, and studying. But the truth is, you are our best and most effective teachers. And for that, I thank you.

Sincerely,
Maria

Categories
Nonfiction NYC Observations

Lunch.

During my first year in New York, I packed my lunches in plastic grocery bags from Morton Williams. That is where I purchased cartons of frozen Shop Rite veggies, picked through Cortland apples, saw packages for matzoh ball soup, and overheard elderly women bicker with cashiers over the price of the deli pasta salad.

My lunches were simple: thin sandwiches, leftover pasta and vegetables, string cheese, fruit, nuts. If I wanted a treat, I’d slip in a few cookies.

Upon sitting down at the round table in the office next to the large windows overlooking the East River, I unwrapped my lunch. Several of the attending psychiatrists showed great interest in my food.[1. I have never before nor since experienced so much fascination from others about my lunches.]

“So… what did Dr. Yang bring for lunch today?

“What homemade goodness are you having?”

Sometimes they stood over me; sometimes they pulled a chair out and sat down, leaning forward to inspect the contents of my lunch.

“What’s in that? Eggplants? Tomatoes? I smell garlic.”

“What kind of apple is that?”

“Leftover pizza, right?”

As I confirmed or otherwise explained the ingredients in my lunch, sometimes they congratulated each other for their discernment. I nodded and resumed eating. They wandered away towards the door.

“So… diner?”

“It’ll be crowded. How about the cart out front?”

“The diner is always crowded, but they make good fries.”

“Okay, the diner it is.”

The team nurse often entered the office after the psychiatrists had left. She spoke with a Brooklyn accent, dressed with class, and carried herself with confidence. Though the wrinkles around her eyes and on her hands revealed her age, she argued with vigor when she disagreed with the director of the service. He would persist, though knew to relent: She was a strong woman.

Sometimes, upon finding me eating alone, she would sit down at the table. She shared history about the department, interesting developments in other parts of the hospital, and updates about patients I had seen.

She also shared her sadness about her son. He was killed while serving in the military a few years prior and the anniversary of his death had just passed. Though she was smiling, her eyes were already full of tears. Her voice cracked as she apologized for crying.

“I miss him so much,” she said, dabbing her eyes with a ball of tissue. As she pulled apart the ball, she murmured, “My mascara is starting to run, isn’t it.” More sad than annoyed, she motioned me to walk with her to her desk. Her computer wallpaper was a photo of her son in his military uniform.

She pulled out a compact and examined her eyes, wiping away the trails of diluted mascara on her cheeks. She was still crying.

The sky was dark. A storm was coming. The arcs of the grey clouds were descending upon the lines of the housing projects and warehouses across the river. Her screensaver began flashing photos of her dead son.

The office door opened; the psychiatrists were back from lunch. The nurse quickly wiped her nose and forced a smile.

“Time to get back to work,” she said, standing up.


Categories
Nonfiction NYC Observations

East 77th Street.

I was standing on the south side of East 77th Street near York Avenue. It was late June and my first night living in New York City. Everything I owned—two bags full of clothes and shoes, travel-sized toiletries, two towels, a disassembled table, a bed, one pot, a laptop computer, and important documents—was in a pile on the sidewalk.

I hadn’t wanted to live that far from the hospital. The broker—tan, fit, and preoccupied—glanced at my documents[1. Formal brokers in New York City commonly want two pay stubs, your most recent tax return, and proof that you have a bank account before renting you an apartment.] and said, “You can’t afford to live near the hospital. But you could live on the Upper East Side. You could take the 6 or the M15 to work.”

Rents increased the closer the apartments were to the subway. I couldn’t afford anything beyond 1st Avenue.

My apartment was a “cozy” studio on the first floor. It was in a red brick tenement, built around 1940, that was four stories tall. White, vertical metal bars adorned the inside of the single window. Jutting out underneath was a rumbling window air conditioner.

There was also a small window in the bathroom that opened to a small, dark enclosure that was littered with cigarette butts and dented soda cans. When that window was open, the aromas of cooking food, the shouts and cursing of people watching football games, and the moaning of men and women having sex often floated in.

The kitchen had a two-burner stove, a miniature oven, and a short fridge. The sink was metal and shallow. There was no room for a table.

The main living space was just large enough for a full-sized bed and a small desk. I got the desk from the man I was dating. It was an old table, constructed of particle board, that he was going to throw out. The tabletop was white and visibly sagging; it resembled a hammock on four rusting legs. I eventually got a small bookshelf. To get to the window, I had to squeeze myself between the bookshelf and the foot of the bed.

The apartment was probably around 250 square feet. Rent was $1550 a month.

Before I learned that the heating pipe in the corner would often clang as the radiator overheated my apartment all winter, that, in this neighborhood, black women often pushed baby carriages holding white infants, that people would fish from the East River before 6am, that lights in the Empire State Building could change color, that up to 1000 people would pour out of Penn Station every 90 seconds[2. “… Penn Station, which is the busiest station in North America, funnelling 600,000 passengers through just 21 tracks, sometimes at the rate of 1,000 people every 90 seconds.”], that my then boyfriend and I would eventually get married in Central Park, before all that–

–I stood on the sidewalk on East 77th Street and looked around. People ignored me and walked around my pile of stuff. Yellow taxis, black Lincoln town cars, and men on bicycles delivering food rolled along York Avenue. Only a few stars dotted the indigo-charcoal sky.

I had a place to live, a new job that would start in a few days, and at least a year to learn about and live in New York City.

I grinned.