COVID-19 Medicine Nonfiction

Stairwell as Sanctuary.

Old, concrete stairwell with brightly-lit windows in the background.
Photo by Ryutaro Tsukata. This stairwell looks similar to the one I frequently used for myriad reasons while I was in residency training.

I wrote the following op-ed in late July, though never submitted it for publication: While I share an opinion, I don’t offer any solutions (and none have come to mind since then). Since President Biden has announced that the pandemic is over, now is the time to share this essay.

There is a stairwell or bathroom in every health care setting that has served as a sanctuary for medical professionals. We hold our breath and stifle our sobs while we stride towards the sanctuary; we wish to get there before anyone sees us weep. The tears fall because we learn a vulnerable patient died. A cherished colleague is leaving. A faceless health insurance reviewer has denied treatment. We run out of options to help someone because of choices an institution made. We wish we knew more, could do more.

As health care professionals, we are familiar with disappointment and sadness. Both are a part of our training and professional experience. We, however, are now experiencing enormous, unprecedented loss. Like ripples on a lake, our reactions to this loss will radiate forth and touch everyone in our communities.

The loss of life from the Covid pandemic looms over us. Over one million people in the United States have died from SARS-CoV2; we provided care to them in clinics, homeless shelters, jails, crisis centers, emergency departments, and hospitals. The individuals did not only die from Covid; others died from social consequences of the pandemic. Under- and untreated medical problems took away quality and quantity of life. Drinking, smoking, and injecting in doses too large offered relief from pain that defied description. Suicide seemed like the best choice among miserable options. We said their names and saw their faces, even as ours were covered with masks and goggles. Out of respect for patient privacy, we do not share these stories. In silence, we think of those who have died. This silence grows because we cannot find words to describe the shape, size, and saturation of our growing grief.

Even if we are able to share our sorrow, we have fewer colleagues around to listen. Diminishing clinical guidance, financial resources, and infrastructure support for health care professionals caused nearly 20% of us to either flee or flame out. (We understand why they left. We think about leaving, too.) Some retired early, others left for jobs that require less contact with distress and disease. They took with them their experience and expertise, which helped not only patients, but also us. Still others, recognizing already limited support dwindling further, took advantage of market forces and took jobs that were circumscribed in time and substantial in compensation. Health care delivery largely occurs in teams. When team members turn over frequently, the lack of team trust and cohesion often erodes the quality of care patients receive.

Earlier in the pandemic, we viewed the CDC as a part of our health care teams, as they have what many of us who work in safety net settings don’t have: Authority, public health expertise, and resources, including time to read and think. Over time, the CDC let us down: Instead of providing reliable and proactive leadership, it dithered. The CDC’s inaction forced individual agencies and clinicians to craft guidance. Why was a psychiatrist left to lead a public health response for a homelessness services agency? We wanted concrete guidance to keep people healthy and out of hospitals; we received a meager menu that deferred to the whims of politics and skeptics. We wanted tests and data to decrease disease spread and deaths; the CDC delayed sending out both laboratory and rapid tests. Recall that wealthy individuals and companies remained at home and procured tests with ease. Meanwhile, people labeled essential workers were treated as inessential: They could not access tests to protect themselves or their families. The CDC betrayed those of us who provide health care; we thus betrayed those who entrusted us with their health.

Health care workers must leave the stairwell or bathroom when our crying stops. Our tears may end, but the needs of patients do not. Physicians experiencing distress may be more prone to making medical errors. Fewer health care workers and disruptions of teams increases the work burden on those who remain, which increases their exhaustion and heartbreak. Without reliable guidance and leadership from a health authority like the CDC, we are unable to deliver unified, coherent health care. This will adversely impact not only the experiences of people who are ill, but will also result in population outcomes no one wants: More disease, more suffering, and more death. It may be too late to reverse this vicious cycle. We wish that we knew more, could do more.

COVID-19 Nonfiction Public health psychiatry

16 People.

Content warning: This post discusses death and suicide.

Photo by George Becker

Early in my training, someone older and wiser than me made a comment in passing:

There are two types of psychiatrists: Those who have had patients die by suicide, and those who have not.

I assume (perhaps incorrectly) that all psychiatrists eventually join the group where someone under their care dies by suicide. These deaths change us.

The first time I learned that someone under my care died from suicide was during my intern year. I didn’t know him well; I do not remember his name. I was working in a psychiatric unit in a hospital and had worked with him for only one or two days. He had a diagnosis of a psychotic disorder. My sole memory of him is his flat, unblinking expression while he looked at me. Though his face showed little emotion and he said few words, he radiated discomfort.

Within a week of his discharge from the hospital, he had jumped off of a bridge.

I didn’t know how to react. I don’t remember if we had a conversation about him, if anything else had happened, or what we could have done differently.

I do remember the name of the person who killed himself after he and I had been working with each for nearly a year. He was the first of “my” patients who died by suicide.

He earned a professional degree long ago, but was living in a shelter. Alcohol brought him comfort, though it drowned his career. He argued a lot. This was the primary way he knew how to interact with people. Despite his pugnacious manner, he and I built and maintained a respectful rapport.

The medical examiner ruled that he had died from an overdose, though the official did not deem this a suicide. The toxicology report stated that there was methadone and alcohol in his system. He did not like and never used opiates.

I still think of him a few times a year. I still wish he had talked to me before he ended his life.

In any given year, I learn that one or two people under my care have died. Most of the time, the cause isn’t suicide. People age; people get sick; bad luck strikes.

Between January of 2020 and June 2022, sixteen (16) people under my care died. None of them died from Covid. The youngest was in their late 20s; the oldest was in their mid-60s. A few died from suicide; others died from medical problems (some acute, some not). Many died from overdoses. Maybe they were intentional; maybe they weren’t. I will never know.

I recently spoke with a former colleague about the various losses we have experienced over the pandemic.

“No one wants to hear it,” she said with some bitterness. “People are tired of hearing sad or bad news, so they don’t ask about our work or how we’re doing.”

She’s not wrong. It’s not easy for me to talk about it, either, as talking about it means I have to think about it, and it’s hard to think about things that do not make sense and may never make sense: What happened? What happened to us?

Maybe I just want people to know that actual human beings died, that I knew these people, that all these people meant something to someone, that they meant something to all of us who had the opportunity to know them. I wish I could tell you more about the guy who made a handmade Christmas card for me, even though he had yelled at me the first time we met just six months prior. I wish I could tell you more about the woman who had several weeks of sobriety before she collapsed on the sidewalk, her heart pulseless. I wish I could tell you more about the man who always called me “Ms. Dr. Maria” and offered me home-cooked food whenever I visited him at his apartment.

That’s only three people. There are 13 others.

If you’ve lost someone during the pandemic, you are far from alone. A poll from 2021 (!) revealed that about 1 in 5 Americans are close with someone who has died of COVID-19. (Recall that over one million people in the US have died from Covid.) Suicide remains a leading cause of death in the US, with certain groups at higher risk than others. (Also remember that we all can help prevent suicides; it doesn’t have to be the only option.)

It’s okay to feel sad, angry, or disappointed; you feel how you feel. Things will change, as they always do, though they may not change as fast as we want them to. It’s also scary to express vulnerability. Voluntarily shedding the crusty carapace to reveal the soft tissue within, however, may be the best (or only) path forward.

Consult-Liaison Medicine

Coping Skills.

Grayscale photo of 11 tall clocks all reading the same time within a grove of trees.
Photo by Pixabay

I recently had a dental procedure that involved local anesthesia. I watched the dentist do her work through the reflection on the examination light. Though I didn’t see the drill, my entire head vibrated from my mouth. The gel she swabbed on my teeth was dark purple; for a few moments, it looked like she had removed them. The tip of the light that bonded the composite material first glowed a neon yellow, then flashed into nightlight blue. I left the office with a facial deformity and a speech impediment, though, thankfully, both disappeared as the anesthetic wore off.

(Science, technology, engineering, and mathematics are amazing.)

Dissociation is a useful coping skill at the dentist’s office. Though I was watching her work on the teeth in my mouth, the anesthetic left me feeling disjointed sensations: pressure and vibration, but no pain. Was this actually happening? My throat reflexively swallowed when the saliva began to pool; sometimes I tasted the metallic salinity of blood—my blood. But was this actually happening to me? My hands rested on my belly, like small boats of muscle, flesh, and bone floating on slow waves of abdominal breathing. A woman whose face I could not see was sanding down teeth. Were those actually my teeth?

When the dentist announced that she was done, I rejoined my body in space and time within one or two eyeblinks. Everything—except for the small, numb portion of my mouth—had reintegrated.

Problems arise when we only have one coping skill to deal with life’s myriad stressors. Imagine disconnecting from time during a job interview or separating from reality when a friend is in distress and needs your help. The interviewer may assume that you are inattentive or intoxicated. Your friend may come to believe that you are unreliable and unresponsive. Doors you wanted to walk through close.

Imagine that any time a challenge appears, the only way you can deal with it is by disconnecting in space, time, and identity. Gone are the abilities to ask for help, defend yourself, or protect people you care about. You just disappear.

Sometimes people end up relying on only one coping skill because it was the only skill that was useful—and lifesaving—in the past. Consider the child who grows up with a father who drinks large volumes of alcohol. When he starts roaring and the dishes shatter against walls near and far, hiding and dissociating are protective. And what if he drinks to this point of loathing and destruction most nights of the week? It seems safer to feel nothing at all rather than terror and tense muscles all the time.

The skills we use frequently—intentionally or not—are the skills we come to rely on.

Medicine Policy Public health psychiatry

Recent Readings.

(Note: There are two purposes to this post: One, to get back into a routine of writing and posting. Two, I moved my website to a different host (those of you viewing the actual website will see that the design is different). Because it will never be perfect (because what is?), I am posting as a public test to fix what needs to be fixed.)

Here are some interesting articles I’ve read recently, some of which are prompts for future posts here:

NPR: Stressed out about climate change? 4 ways to tackle both the feelings and the issues. I am largely unfamiliar with the literature on psychiatric conditions and climate change, though have read a paper or two (not recently) about the association of increased violence among people with increases in temperatures. I must also confess that that my current faith in psychiatry to address this in a practical way is brittle: Organized psychiatry (in the United States, at least) seemed unenthusiastic about supporting population mental health during the pandemic. Despite the urgent mental health consequences of Covid-19, organized psychiatry in the US seemed instead enamored with the topic in the next bullet point.

Wired: Is the Psychedelic Therapy Bubble About to Burst? A new paper argues that excitement has veered into misinformation—and scientists should be the ones to set things straight. I find myself feeling annoyed with the mushrooming ecstasy related to psilocybin and LSD (see what I did there?), among others. There are a number of reasons for this; I will be the first to state that some of my reasons are not valid. Much of my irritation stems from the limited evidence (at this time) to support psychedelics for more severe conditions, the limited number of people who can actually access this intervention (who can afford this? who has eight hours to spend with two therapists?), and why We as a Society do not instead invest in population-level interventions so fewer people will develop trauma-, depression-, and anxiety-related conditions (e.g., ensuring children aren’t hungry; supporting literacy and education so people have skills for employment; etc.).

The Hill: Suffering from burnout, doctors are working drunk or high on the job: report. A new report found the health care industry has been too slow to address its mental health crisis among doctors and nurses and often treats mental health as secondary to physical health. “Over the last three months, 1 in 7 physicians admitted to consuming alcohol or controlled substances at work.” This data came from interviews from a mental health company, so there’s potentially a lot of bias in the results. I am sorry to say, though, that I wasn’t surprised to learn this. Some health care workers were drinking or using controlled substances at work before the pandemic.

n+1: Lab-Leak Theory and the “Asiatic” Form. What is missing is a motive. I did not find this to be an easy read, though it engaged me enough that I was able to get through it. In short, the author, Andrew Liu, argues that the appeal of Covid-19 coming from a lab leak is a reflection of historical (and ongoing?) exoticization of the Orient, as well as fears of China’s economic power.

New York Times: Yes, We Mean Literally Abolish the Police. and Truthout: I Stole to Feed My Family and Was Incarcerated. We Need Resources, Not Prisons. I am not an abolitionist, though there are days when I wish I could be successfully persuaded to become one. (This reflects what appears to be my declining idealism as I age.) To be clear, I do not think incarceration has been or is an effective solution for many (and maybe most?) behaviors and problems. This conclusion comes from my experience working in a jail and with people who are poor and marginalized. However, examples easily come to mind for how law enforcement and incarceration have had some value: Consider Jeffrey Epstein or Ted Bundy. I don’t know what the answer is, though I do not think either pole (e.g., police state or abolition) are useful or desired solutions. I am open to changing my mind. (Related: This Twitter thread on the role of child protective services.)

New Yorker: The Lottery. Shirley Jackson wrote this short story in 1948 and I only learned of it in 2022! If you’ve never heard of it before, please go read it: It has excellent structure, which helps drive the story to its haunting and disturbing conclusion.

Policy Public health psychiatry Systems

Writing Down Words.

It’s been five months since I’ve posted anything… and not because I had nothing to say. As Gloria Estefan and the Miami Sound Machine sang:

But the words get in the way
There’s so much I want to say
But it’s locked deep inside

… except it was Covid that was breaking my heart. I still feel like I have aphasia when people ask me what happened and how I am doing. At least now I am able to blurt out some emotion words (“I was angry, but it’s really because I was profoundly sad”).

In the meantime, work I did during my tenure as a medical director at King County got some press: Why King County mental health facilities decline 27% of referrals. (The only reason why I agreed to have my photo taken for the Seattle Times piece was to give my dad something to smile at.) Here’s what I learned from this experience:

Write stuff down and share it. I left my position at King County in 2019. I wrote a report on this data every year between 2015 and 2019. I sent it out to relevant organizations and officials, whether they welcomed it or not. The Seattle Times journalist somehow discovered the 2019 edition of this report earlier this year. I am grateful that she found it interesting enough to publish it in the local paper of record. If you think it’s important, write it down and share it. Someone will eventually find it useful. (I suppose this is an underlying tenet of those of us who still write in blogs.)

Sometimes it’s easier to talk about stuff once you’re outside of the organization. Government, at all levels, has its communication protocols. Depending on where you sit in the hierarchy and what your status is, you may not be permitted to talk to the press. Or you are counseled to adhere to specific talking points. (I recall sitting for an interview with a local weekly publication; I was only allowed to speak to the journalist if one of the county communication officers sat next to me.) For this, my speech was more free.

People want to learn. The photographer and I met at a public staircase. I said, “I probably shouldn’t smile, since this isn’t a joyful topic.” She had a general sense of the article and asked questions. By the end of our time together, she learned about psychiatric hospital data and I learned about the experiences of newspaper photographers.

Ezra Klein interviewed Dr. Thomas Insel, a former director of the National Institute of Mental Health, on his podcast (“The psychiatrist and public health expert Thomas Insel discusses how mental illness is a medical problem that requires social solutions.” Dr. Insel’s formulation here is catchy, though oversimplified.) I appreciated Ezra asking Dr. Insel to clarify and elaborate on some of his statements. Dr. Insel and I, though both psychiatrists, have had different professional experiences. As a result, I offered the following reactions to Ezra and his team:

There is an overlap between people with serious mental illnesses and poverty, which is where social solutions may be the most effective. People with serious mental illnesses (e.g., schizophrenia, bipolar disorder, etc.) are often at greater risk of poverty. For example, someone with a diagnosis of schizophrenia may be unable to sustain employment, accrue hospital bills that they cannot pay, and end up receiving more attention from law enforcement. Conversely, poverty can exacerbate serious mental illnesses. For example, adolescents may run away from home due to domestic violence or other dangers at home. If these teenagers do develop psychiatric symptoms, they often have limited support to seek and access services (health care or otherwise). Social solutions (e.g., housing, supported employment, etc.) may only work for individuals who experience both serious mental illness and poverty. Many of the interventions Dr. Insel listed–clubhouses, job training, supportive housing–are available only to those who have Medicaid insurance, which, as you know, requires low income.

Psychiatric treatments in the US, for better or worse, occur within an American/European frame. Dr. Insel extolled the virtues of medications and psychotherapy (and, to be clear, he’s not wrong—the current evidence base supports the use of both for many psychiatric conditions), except these interventions have Western European origins (hence his reference to Freud). Different ethnic cultures and American subcultures may be uncomfortable with or outright reject the American system of diagnoses and treatments. There is evidence that indicates that Black people are more likely be receive diagnoses of schizophrenia and antisocial personality disorder, which remain two of the most stigmatizing diagnoses in psychiatry. This isn’t limited to race only; women seem more likely to be diagnosed with anxiety and depression. (Is this a remnant of antiquated ideas related to wandering uteruses? or because women are more likely to seek medical help for their concerns?) The traditional health care system has expectations about how people will present and express their concerns; it also has expectations about how people will receive and accept care. From an intersectional perspective, this may contribute to why certain populations are less likely to seek and accept psychiatric services.

Policies and culture are intertwined. I appreciated Ezra’s commentary about the role (or lack thereof) of policy as it relates to isolation and serious mental illnesses. I agree that that policies can only go so far to help promote social support and connection. Perhaps Ezra and Dr. Insel were trying to discern how current US culture reflects a lonelier society, and how policies can or cannot influence US culture to help reverse this? Policies come out of the current culture, but policies can also impact culture (e.g., women’s suffrage, civil rights, abortion bans, etc.).

Though it’s hard to prove the success of prevention, that may be the best way to address all three issues above. Because most of my work has been in the “deep end” of the system, I have become an ardent supporter of prevention and early intervention. (At the risk of sounding really self-righteous, I’d love to work myself out of a job!) So many people I’ve had the privilege of caring for have experienced terrible physical, mental, and sexual trauma as children and adolescents. What would it be like if people weren’t molested or assaulted when they were kids? What would it be like if pregnant people didn’t experience violence from their partners? What would happen if youth who identify as LGBTQ+ experienced acceptance and support from their families? What if emotional self-regulation skills were part of prenatal care and school curricula? These prevention efforts can be folded into policy, which can influence culture. Reducing (minimizing? eliminating?) poverty through policy could improve outcomes not only for mental health, but for physical health. (The Spirit Level by Wilkinson and Pickett provide some compelling data about this.) Ensuring that psychiatric interventions and treatments from non-American/European frames are funded and evaluated for efficacy not only increases treatment options, but these non-Western treatments may also appeal to different populations.

Funding for the mental health and substance use disorder systems is complicated; it took me years as a medical director to understand how it works at the county level. Funding systems should follow the clinical delivery of services, but, unfortunately, the delivery of psychiatric services (as with the rest of health care) is based on funding systems. This makes implementing services, accessing care, and improving outcomes needlessly challenging for actual human beings. While the 988 line is an encouraging development, I worry that, if the crisis system is the most robust part of the psychiatric care system, then crisis care will be the only place where one can get quality care. And no one should have to experience one of the worst days in their life to receive good care.

I can’t help but observe how my reactions above can also apply to how the US has responded (or not) to the Covid pandemic. I continue to grasp at words.