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Education Seattle Systems

Recommendations to other physicians from Washington re: COVID-19.

This post isn’t polished, but (a) it seems important to get this information out and (b) it also helps me feel like I have some control over something:

I work as the medical director for a non-profit agency that serves people who are currently or formerly homeless.[1. This post is NOT on behalf of my employer! I am writing as a private citizen who has opinions.] I am trained as a psychiatrist and have previously worked in local government. I live in the county in Washington State where people have died from COVID-19.

Here are my recommendations for other physician leaders in other regions, particularly those who work in outpatient, non-profit settings. I hope this information can help you if once COVID-19 arrives in your area.

Start talking with other physician leaders that intersect with your work now. Talk about how you all will coordinate together. How can your teams all work together to ensure that only people who need ED-level services are sent there? What sort of screening will you all do? If people who don’t have homes need to self-isolate, where can they go? Establish a communication system now because when COVID-19 arrives, you don’t want to fumble through that. If you haven’t met these other people yet, meet them now.

Start talking with physicians who work in your local government. My observations thus far are that physicians in government haven’t been active in planning for systemwide medical issues, and not because they’re not interested, but rather because they are overwhelmed and there’s not enough of them. Start asking questions like: if people who are homeless need quarantine, where should they go? has the city or county started talking with the hospitals to determine a system of where people with COVID-like symptoms should go? who will get tested? is there a centralized phone number clinics can call to alert county authorities of outbreaks? what sort of communication is the city or county having with the state?.

Keep up the advocacy with state and local partners with questions related to system processes. The state and local partners likely won’t have answers, particularly if you serve underserved patients. Since COVID-19 is affecting everyone, governments are thinking about the majority of people, many of whom are the “worried well”, can self-isolate, can go see their own doctors, etc. People without the same resources can’t do the same prevention and early intervention activities, so it is vital to keep following up with government partners so they don’t forget about these underserved populations. (This also includes populations that may not seek health care services, like immigrant and refugee populations.) If you can keep up the questions to your physician partners in government, they will feel empowered to keep asking their partners (e.g., state and federal agencies) for information.

Start teaching stuff to your non-medical partners. Sometimes physicians and nurses forget what we know; we think everyone knows what we know. Agencies that serve homeless populations often don’t have medical staff, so their leadership and line staff may have questions like, “Will an air purifier eliminate COVID-19?” or “Will hydrogen peroxide kill COVID-19?” People may not know HOW to wash their hands. Advocate with your agency leadership to get hygiene supplies now (because most of the suppliers locally are sold out) and make it easy for your staff to practice good hygiene. And don’t make assumptions that people know how to do hygiene stuff.

A small minority of people will do things you won’t like. There are people calling health care agencies pretending that they are the WHO or CDC and are asking for financial information so they can steal money. Supplies, like face masks, may suddenly go missing. Prepare for these sort of disappointing behaviors.

You can’t overcommunicate. In the face of uncertainty, frustration arises. Don’t lie, either; tell people what you know and don’t know. That way, they will be more likely to trust you when you do have recommendations.

Support your staff. You can’t rely on your staff to take care of other people if your staff don’t think you are taking care of them. We heard a comment today during a phone call that an estimated 40% of staff will be out of the office due to illness. Some may also call out because of fear. We can appeal to the better natures of our teams, but they won’t rise to the challenge if they think we don’t care about them. And if they don’t think we don’t care about them, then they won’t have the emotional and cognitive capacity to care for patients. (This applies to local government, too: They must take care of the agencies that provide services on their behalf, or otherwise the agencies will feel unsupported and may not extend themselves.)

People are expressing and demonstrating anxiety, which is fine—there are reasons to worry. But there are things we can do as leaders to acknowledge and mitigate that anxiety. Start now.

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Homelessness Nonfiction Reflection Seattle

Remembering.

There were three shootings in a 25-hour period in Seattle this week. The third shooting occurred during rush hour. Multiple fire trucks raced past the lines of cars in the downtown grid; I remember thinking, “It must be a big fire.”

The newspaper later reported that the person who died in the third shooting was a woman who was previously homeless, but now had lived for nearly ten years in permanent housing. Based on her history of homelessness alone and the location of the shooting, some people might assume that she made an active choice to be there, that it was somehow her fault that she was shot. Would those people also assume that the others who were shot—including the nine year-old boy—made an active choice to be there, that they are to blame for getting shot?

There is now a vacancy in that apartment, and people will miss her.

Two days prior, I went to a homeless shelter with hopes of talking with a patient. He wasn’t there—maybe he was trying to avoid me; maybe he forgot; maybe he had more important things to do—but there was a makeshift memorial in the lobby.

As I made my way to the memorial, a man with fresh scabs all over his face and pants too big for his legs walked past. A woman with grey hair leaned forward and used her skinny legs to roll backwards in her wheelchair.

On the folding table was a grayscale image of a man’s face printed on a standard sheet of paper. The image was blurry due to the low resolution, but his smile was bright and clear. Next to this image was a large sheet of white butcher paper, along with some pens.

Several dozen people—other people staying in the shelter—had written messages on the butcher paper:

You went too soon, man.

I miss you and hope to see you again in heaven.

I hope it’s better where you are now.

Another person had already taken the bed that this deceased man previously occupied.

She was trying not to cry.

“It’s completely normal to feel sad when one of our [patients] die,” I said. “You were connected to him.”

A small laugh came out of her mouth, and then the tears fell from her eyes.

He wasn’t an old man, but he wasn’t a spring chicken, either. He didn’t like to stay in the shelters; sometimes other men would call him names or make fun of the way he talked. He slept under a bridge, though came into the clinic several times a week. He and I had only met once; he was courteous, made small jokes, and called me “ma’am”. I wished that he would stop smoking methamphetamine. He wished for that, too.

She, his case manager, was hopeful. They talked about his health; they worked on applications to help him get into housing so he didn’t have to stay in a shelter or sleep outside; they talked about how methamphetamine was getting in the way of what he wanted.

“I wasn’t prepared for this sense of loss,” she said, wiping her face. “We talked about his plans. I was hopeful that things would change for him.”

A few weeks prior, he was sitting across from me in that office. She and I now sat there, our sadness filling the room.

I have a friend, also a psychiatrist, who works in a prison. She has commented that these individuals—people living on the streets, people in jails and prisons, people who are part of marginalized and excluded populations—are considered “throwaways”, that people don’t think about them, that they are the forgotten ones.

We only forget about them if we forget that they’re people, just like us.

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Medicine Nonfiction Reflection

Clinical Training and Butt-Grabbing.

Under duress, we do not rise to our expectations. We fall to our level of training. (Bruce Lee… supposedly)

When I was looking for My Patient, well before his neighbor grabbed my butt, I remember noticing that most of the slots in the doors of the isolation jail cells were open. These slots are tall enough to pass a softball and wide enough to pass a clipboard. They are about three feet up from the ground. The slots function like small doors: The hinges are on the bottom, so the slot doors fall open when unlocked. Only people on the outside—-correctional officers—-can unlock and open the slots. The slot doors automatically lock when closed shut.

The slot in My Patient’s door was open, as was the slot for his neighbor. Before I started talking to My Patient, I remember thinking, “Maybe I should completely shut his neighbor’s slot.” I shrugged that thought away: I had been working in the jail for over five years and nothing had happened to me before. I partially closed the neighbor’s slot in a vain effort to provide some privacy to My Patient. While standing between the two doors, I leaned over to talk to My Patient, who I was meeting for the first time, through his slot.

My Patient, calm and civil, had spoken with me for only a few minutes when I felt fingers grab a handful of my gluteal flesh. In less than one second my mind had deduced what had happened: My Patient’s neighbor, who I did not know, had pushed open his slot door, reached out, and grabbed my butt, which was covered in a white medical coat. Before I reacted, he also cackled with spite, “Shake that Chinese ass!”

There are many ways I could have reacted:

  • Scream.
  • Yell, “Don’t touch me!”
  • Shout, “What are you doing?!
  • Holler, “What is wrong with you?”
  • Exclaim other combinations of profane and proper words to express my displeasure.

But what did I actually do?

“EXCUSE YOU!” I exclaimed as I whirled around. I caught a glimpse of his face as I slammed his slot door shut.

I still laugh at my reflexive reaction. There was no thinking involved. Nonetheless, my non-thinking brain still generated the phrase, of all the possible responses that are applicable in this situation, “Excuse you!” The emphasis on professionalism in training and in practice had prepared me for this day.

(Of course, the more emphatic point was slamming the slot door shut. The importance of boundaries was reinforced in training and in practice.)

I then took a breath, turned back to My Patient, and said, “I’m sorry about that. You were saying?” He resumed talking. We both pretended like nothing happened.

Though no one witnessed this event, my colleagues believed me. (Let’s be clear, though: The differences in social status alone—-physician versus jail inmate—-tipped the scales heavily in my favor.) This was the first time I had ever experienced a stranger grabbing my butt. I had announced my resignation from my position in the jail (and an administrative role in county government) just a week prior, so my colleagues, after offering support, quipped that of course this was ordained to happen.

What this event highlighted to me, though, was the respect most men show to most women most of the time, whether in or out of jail. While it is entirely possible that men everywhere are exerting great, continuous restraint from reaching out and grabbing the butts of women, I don’t get the impression that such self-control is exhausting their energy reserves. In my five years working in jail with individuals who are often demonstrating significant behavioral disturbances, this was the only time someone grabbed my butt. This suggests to me that most men—-even men in stressful conditions like jail—-have intact impulse control or are least willing to adhere to social norms about butt-grabbing.

To be clear, though: I hope I never encounter this man ever again. (And, as of this writing, he is still in jail. I got out; he’s still waiting.)

Categories
Nonfiction Reflection Systems

The AirBnB Listing.

Had the AirBnB listing included more details about the neighborhood, we probably would’ve stayed elsewhere.

It was lovely: It was a cabin off of a gravel road in a rural area. Fragrant trees towered over the hot tub surrounded by manicured gardens bursting with blossoms of red, peach, and violet. Chirping crickets lulled us to sleep and the songs of warblers and sparrows heralded the rising sun.

The AirBnB listing didn’t advertise the faded truck driving through the neighborhood, a red, white, and blue flag the size of a queen-size sheet flapping from its bed: “STOP THE BULLSHIT: TRUMP PENCE 2020”.

The AirBnB listing didn’t highlight the hand-painted signs leaning against the campers that faced the highway:

     Trump is
   bRinging
     United states back to real
   aMerican
     People

The AirBnB listing didn’t describe the tree farm down the street. The scarecrows guarding the short saplings wore plain white robes adorned with white hoods. Were we reading too much into that?

When we saw the roadside diner, we kept driving because we saw that the first letter of the three words in the name were all K. Maybe locals called it the “Triple K”; maybe it was just meant to be “kute”. Maybe we were reading too much into it.

Nonetheless, we felt like we were in the minority, that we were outnumbered, that we didn’t belong there.

Though we speak impeccable American English, we made a point of greeting people first so they could hear that we were Americans, even if some people don’t think we look like them. We said please and thank you, we smiled and deferred, we were demure. We were model minorities.

Why did we do that? Why did we assume that all people in regions that support Trump would not want us there? Is it fair to assume that all people who support Trump hold racist beliefs? That they believe that we Asians eat dogs, can’t drive, and are socially incapable? Did we think that, if we tried hard enough, we could change their minds?

The AirBnB hosts saw my profile photo when I requested to stay in the lovely cabin. I am obviously Asian. They could have rejected my request, but did not. When we met our hosts—an older white couple, one a military veteran—they were courteous and civil. Even though there was a firearm depot down the road, the hosts had posted signs on their property stating that guns were prohibited. Didn’t these data points reassure us?

And yet: What did they really think of us? Were they simply willing to take our money, even if they thought we didn’t belong here?

Such is the creeping toxicity of racism: You don’t actually know when you should be worried, so you always worry. Even worse for those with darker skin, if you can’t be sure when your life is in danger, then you always feel like your life is in danger.

The toxicity of racism creeps in both directions: Those white individuals who fear that people of color will outnumber, replace, or dominate them also carry this chronic cognitive cargo, even when surrounded only by white people.

Despite climbing mountains bursting with wild flowers, admiring snowy peaks of nearby volcanoes, and appreciating the shade of pine and spruce, we never fully escaped the worry about racism or the worry that we were reading too much into things.

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Categories
Medicine Nonfiction Observations Reflection

Work Spouses and Mentors.

I recently had dinner with a good friend. He and I trained together at the same time and he has since gone on to become a super fancy academic psychologist on the East Coast. Over dinner, he opined that an optimal work situation includes two components: a “work spouse”, and a mentor.

“The work spouse is at the same level as you—same training, same work,” he said between bites of lasagna. “And a mentor is a mentor.”

“Yes!” I exclaimed. My mind recalled the respect and affection I had for all of my “work spouses” over the years:

  • Chris and Sohan both made me laugh, helped me with the endless scutwork to get me out of the hospital, and helped me keep things in perspective when we were interns.
  • Ryan, Scott, and Ryan also made me laugh, provided thoughtful clinical consultation, and gave sage personal advice while we became less human during residency. There was even that time when we were all on call on the same night, but at different sites… and we called each other sometime between 3am and 4am just to check in. Ryan and Scott also taught me how to throw a football; the other Ryan taught me how to improve my storytelling.
  • Sharon made me laugh during fellowship (do we see a theme here?) and provided an international perspective about community psychiatry. Sharon and her husband also invited me to experience a Passover Seder.
  • Joe made me laugh (…) and helped me cope with the stress and discomfort of 15-minute medication appointments. He also validated my opinion that such a model neither matched my values nor allowed me to provide the care that I believe people deserve.
  • Craig also made me laugh, helped me think through difficult clinical quandaries, and also validated the privileges and challenges associated with working in a jail.

In two cases I didn’t have a “work spouse”. They were both medical director positions… and in both instances I was the only physician who worked in those parts of the organizations. Let me be the not-first to say that, yes, doctors think about and approach things differently. Sometimes it’s useful; sometimes it annoys the heck out of everyone else. It’s often isolating: On the one hand, sometimes people elevate an opinion simply because it comes from a doctor; on the other hand, sometimes people disregard an opinion because the doctor’s perspective seems irrelevant. Both reactions are problematic.

“I haven’t had a mentor in years,” I said after a long pause. “Maybe that’s because there aren’t a lot of Asian women who work in public sector psychiatry?”

That might be true, but I don’t know that for sure (though, as I have progressed in my career, it seems that there are few psychiatrists who choose to work in public sector, non-hospital, non-clinic settings). My mind ran through the people I have considered mentors:

  • Randall, a gastroenterologist, taught me in medical school how to remember that patients are people.
  • James, a psychiatrist, highlighted the intellectual rewards of psychiatry and is arguably the person who persuaded me to pursue a career in psychiatry instead of internal medicine.
  • Matthew, an infection disease physician who longtime readers recognize at the Special Attending, demonstrated the intellect, kindness, and humanity that we want our doctors to possess. He was one of the few attendings I worked with who brought cold water and warm blankets to patients when they requested them.
  • Dick, a pharmacist, not only knew a ton about medications, but also dispensed Taoist wisdom about how to manage people in distress… including ourselves.
  • Deb, a psychiatry residency program director, demonstrated a steady grace and cool serenity despite the tumult of resident distress. I still recall and admire her steady support and faith.
  • Brad, a psychiatrist, taught me that “patients are called patients because they are patient with us” and that, while we have the privilege of helping people, we should discard any “rescue fantasies”. The true heroes are the patients, not us.
  • Sarah, a psychiatrist who worked as a medical director for a major US city, validated my interest in working at the boundaries of fields and also encouraged me to apply for positions that I thought were out of my league. “If something scares you, you should do it.”
  • Van, the only boss I’ve had who is both a psychiatrist an a person of color, continues to provide sage career advice and said that words, “Everyone should receive high quality psychiatric care, whether they go to a nice office on Park Avenue or if they sleep on a bench.” Just knowing that someone else thinks that makes me feel less lonely.

At the risk of sounding woo-woo, though, we can all find mentorship everyday. Everyone can be our teachers if we are willing to be students. I think about the bus driver who greets everyone with a warm smile, but has no qualms about commanding—firmly, but politely—a rider to stop harassing vulnerable people who are also on the bus. Consider the finance officer with no formal authority who speaks up during a meeting to advocate for more transparency in fiscal affairs. What about that coworker who picks up the litter in the lobby when he thinks no one is watching? Because he wants to leave a place looking better than it did when he walked in?

If you are fortunate to have a work spouse, bring him or her a treat. If you don’t think you have a mentor, remember that there are others who can provide guidance and inspiration.