Categories
Consult-Liaison Informal-curriculum Lessons Medicine

You Don’t Have to Like Everyone.

You don’t have to like everyone under your care. And you probably won’t, which is okay.

Own how you feel. If you insist on telling yourself that you should like someone when, in fact, you don’t, it will come out in other ways: The tone of your voice, the expressions on your face, the way you position your body.

There might completely understandable reasons why you don’t like the person under your care. Maybe he never seems to hear what you say. Maybe he doesn’t follow any of your recommendations, but he blames you for lack of healing. Maybe he expresses opinions you find offensive. Maybe he calls you racial slurs. Maybe he’s thrown things at you. Maybe he threatens to rape you. Maybe he’s told you that he will kill you and your family.

People do things like that for reasons that make complete sense to them. You may disagree with or misunderstand their reasons, but despite that, they are still people. Even though you may dislike some people under your care, you must still recognize that they are still human beings. The moment you refuse to recognize the humanity of the other person, you are at risk of inflicting violence upon them. Violence can manifest in many ways, including neglect.

First, do no harm.

It is possible to dislike someone and do no harm.

When we don’t like someone, it is much easier to assign blame entirely to the other person (e.g., “He’s an annoying @$$hole”). While it is possible that the problem has nothing to do with you and everything to do with the other person, that doesn’t change the fact that you cannot control other people. You can’t make someone less of an @$$hole. You, however, can make yourself view the situation in a different perspective.

Own how you feel. Let’s say he is, in fact, an @$$hole—something you cannot change. What if you focused instead on yourself?

“I really don’t like him. I feel dread whenever I have to see him.”

The reasons behind your dread make complete sense to you. When you acknowledge your dread and dislike to yourself, you give yourself more options as to how to proceed. You now have more control over the situation.

When you don’t like someone who is under your care and you acknowledge this, you can:

  • get support from your trusted colleagues. You can tell them how much you don’t want to see this person, how anxious and annoyed you feel about having to do this, and how much you don’t like this person. Get it out of your system ahead of time so you can be the professional you want to be when you actually see this person.
  • activate your internal coach. You can take some deep breaths and say a silent prayer before the interaction begins. You can rehearse some evacuation plans in case things start to run off the rails. Your internal coach can recruit your internal cheerleaders afterwards if the conversation goes well.
  • pause and remind yourself of your purpose. Your job does not include judging or shaming the person under your care. Your job isn’t to like the person under your care. Your job is to help the individual improve his health. Sometimes the people you care for have terrible life circumstances that contribute to the behaviors that you don’t like.
  • ask a colleague to see the individual so you don’t have to. Sometimes it is clear that the clinical relationship won’t work out at this time. We can’t be effective with 100% of the people we see (though we can try). Sometimes, the best way we can help the people under our care is to remove them from our care. (Sometimes, though, this isn’t an option.)

It’s often helpful to focus on the behaviors of an individual. When you focus on behaviors, you are more likely to remember and respect the person’s humanity. This keeps us professional and kind, even if we aren’t warm and smiling.

Indeed, he may do things that you don’t like… but he may also do things that you do like. And when we offer genuine thanks to people when they do things we like (e.g., “Thanks for your patience while I was asking you all of those personal questions,” “Thanks for summarizing your story quickly for me,” “Thanks for not calling me names today”[1. I have actually said, “Thanks for not calling me names today!” to people under my care and, no joke, the vast majority of them never address me with bigoted phrases ever again.]), people are almost always going to do those things more often.

You don’t have to like everyone under your care. Once you start owning how you feel, though, you might find that, most of the time, you do.

Categories
Observations Systems

Devastation and Vulnerability.

We are all devastated that children died. Again.

Even though we know that the causes are complex, we want to reduce the issue down to one factor.

“There’s not enough access to mental health services!”

“Agencies with oversight didn’t do their job when they learned concerning information!”

“We need gun control!”

It’s complicated.

We are all devastated that children died. Again.

When kids of color die in mass shootings, do they get the same front page headlines? prime time coverage? threaded tweets with tens of thousands of likes?

Many people who own guns never shoot people. They never craft plans to kill other people. They don’t have impulses to kill themselves.

Is it fair to blame only guns and take them away from people who own them, when most are responsible citizens?[1. To be clear, I do support more regulation on firearms. It is possible to support responsible gun ownership AND gun reform.]

Many people with psychiatric disorders never kill people. They never craft plans to kill other people. They don’t have impulses to kill themselves.

Is it fair to blame only psychiatric disorders and the people who experience them, when most are responsible citizens?

We are all devastated that children died. Again.

Many have expressed displeasure with the wide and toothy smile in the photo, his thumb extended for all to see.

Is it fair to blame only him and his administration, when nearly 63 million people voted for him? Most of whom are responsible citizens?

We are all devastated that children died. Again.

This devastation is a reaction to learning the news that young people died through no fault of their own.

Was the murderer’s decision to kill young people at a school a reaction to something else? Was it a self-contained reaction, a reaction born solely of the release and reuptake of serotonin and dopamine and epinephrine and acetylcholine?

Or was it a reaction to the trauma that all young people experience as they live through the cruelties and injustices of the world?

Why was this—killing students with a gun—his reaction?

What is the reason behind your reaction to him?

Or is your reaction due to multiple reasons?

Are we all blind to the hubris of blaming one thing, one condition, or one person? How are we so sure?

We are all devastated that children died. Again.

To sit with our devastation, to embrace it and understand how it affects us, to witness how it shapes what we say and do, is hard. To acknowledge that our emotions don’t feel under our control, to realize that feeling pain makes us vulnerable, is hard.

It’s hard for everyone else, too.

We must accept and respect the vulnerability in ourselves and others if we want our reactions to change. Only then will the devastation will stop.

Categories
Nonfiction Observations

Expectation.

He was scowling all morning, so I decided it was worth a try.

“Hi.” I leaned in. “What is orange and sounds like a parrot?”

Still scowling, the jail officer working in the psychiatric unit glanced at me, then tapped his thumb a few times on the desk.

“I dunno. What?” he mumbled. At least he was willing to play.

“A carrot.”

It happened in less than a second: His face softened, he rolled his eyes, and then the groan became a chuckle.

“A carrot! That’s so stupid!” The wrinkles around his eyes danced as he smiled.

Success!

The inmate was pacing the length of the block. The uniform was too large for his slender frame. Though the cut was uneven, his hair was shiny and thick. Further evidence of his youth included his smooth and unmarked skin.

The jail officer, grinning, walked towards the inmate.

“Hey, Doe,” he started, his voice smug, “what is orange and sounds like a parrot?”

The inmate stopped walking, but made no eye contact with the officer. The officer looked at him with expectation and condescension.

“A carrot,” the inmate replied, as if the officer had asked him the time. He immediately resumed walking.

Crestfallen, the officer frowned. “Even he knew that one?”

I turned around so the officer couldn’t see me smile.

Categories
Medicine Nonfiction Reflection

On Trusting Doctors.

There exists a particular physician who many in medicine regard as a quack: She has argued that HIV does not cause AIDS. She has written many pieces stating that vaccines are toxic and cause diseases such as autism, depression, and SIDS (sudden infant death syndrome). Within certain circles she enjoys great popularity. Her medical doctor credential lends her an authority that these circles highlight in their efforts to denigrate medicine.

I know her. Our paths crossed at one point during our medical educations. At that time, she and I worked in the same hospitals and saw people who experienced not only profound illness, but also suffering related to poverty, violence, racism, and other factors that impact health.

At that time, she believed the science that HIV causes AIDS. We never talked about vaccines, but I know that she believed the science of immunology and molecular biology. She and I, along with others in our cohort, exercised critical thinking when reading and discussing journal articles.

She and I were never close, but we were friendly. She was the first person to acknowledge my engagement. We were sitting across a table while someone gave a lecture. She pointed at her fourth finger, then pointed at mine, now adorned with a ring, and gave me a bright smile.

Many years have passed since we last saw each other. I wonder what happened to her.

To be fair, our beliefs and practices share some overlap: She apparently doesn’t prescribe medications at all. I try to avoid prescribing medications when possible. She has reportedly helped people come off of medications. I have, too. She encourages the application of exercise and other nonpharmacological interventions. I do, too.

From what I can tell, those are the few characteristics we now share.

If I am honest, I feel more anger than disappointment about her practice. As I understand it, she apparently charges over $4,000 (yes, over four thousand dollars) for an initial evaluation (that lasts for two hours) and one follow-up appointment. Every 45-minute follow-up thereafter costs almost $600. It also sounds like that people who wish to see her must fill out a questionnaire, which she uses to screen people into or out of her practice.

How many people can afford to pay $4,000 for an initial evaluation? Yes, I understand how scarcity makes something or someone seem more valuable, but $4,000? People who can pay that amount—plus the $500+ for each follow-up appointment—have access to other resources that make options other than medication possible. Furthermore, if her screening questionnaire weeds out people who want (or need) to take medication, that means she is unlikely to see people with moderate to severe symptoms.

Most people don’t want to take medications. Most people try everything they can with the resources they have before seeing a doctor. Unfortunately, the current healthcare system drives and rewards physicians for prescribing medications, even when that isn’t the optimal intervention.

Furthermore, this $4,000+ results in the potential spread of false information. I don’t know what she’s doing during that initial assessment—my guess is that it involves a lot of listening—though I doubt she’s persuading everyone to avoid vaccines or that HIV doesn’t cause AIDS. I don’t know; maybe she is. Though, given her popularity in certain circles, selection and confirmation biases are already active: Only those individuals who already share these beliefs would seek care with her.

As much as the above bothers me, what irks me the most is the seeming waste of her training and talent. Our training paths crossed, yes, but look how they have diverged! She charges literally thousands of dollars to provide care for people who are unlikely to experience significant symptoms. Given the economics of her model, most of the people she sees are likely upper middle class to upper class white people.

The individuals under my care, both past and present, are often people of color with significant symptoms who have few resources, often through no fault of their own. For those who don’t wish to take medicine, we work together to help them obtain a job, secure housing, or avoid the attention of the police. Those individuals who take medicine often find that their quality of life improves by leaps and bounds: They are able to stay out of the hospital. They remain employed. They spend time doing the things that matter to them.

To be clear, upper middle class and upper class white people also experience severe psychiatric conditions. Major psychotic, mood, and substance use disorders don’t discriminate. People without money and access to resources, though, are likely to fall farther and have a harder time catching up once symptoms appear.

Let’s assume for the moment that this particular physician who charges $4,000+ for an evaluation has developed a treatment model that really helps people without the use of pharmacology. Why not share that model? Why not work with researchers and other physicians who can adapt this model to people who can “only” afford $500 for an initial consultation? Or $100? Or $5?

This physician knows how to work with and provide successful treatment to individuals with major mood and psychotic disorders. I’ve seen her work. While I have no doubt that the individuals who are able to spend $4,000 on an initial evaluation are suffering, what about all the other people who suffer who will never be able to afford that consultation? If the treatment model really works, why limit it only to the people who have that kind of money?

Why not ease the suffering of as many people as possible?

Could it be that the powers of confirmation bias, scarcity, and placebo are the keys behind her treatment model? That $4,000+ buys chiefly status and expectation? Does it matter that unfounded, dangerous claims are part of the deal?

Should you always trust a doctor?

Categories
Homelessness Nonfiction Policy Systems

How to Prevent All of This?

Some of the people under my care in the jail right now are quite ill. (This statement is always true, but it seems that the intensity of illness is greater now than usual.) As a result, the perennial question seems more urgent now: Is there any way to prevent All of This?

For some of them, it seems that the answer is No. Some of them sought out psychiatric services, attended appointments regularly, and had good working relationships with their physicians and therapists. They shared their concerns with friends and family members; they sought out help when they started feeling overwhelmed. Despite these relationships and support, they allegedly did things that resulted in significant criminal charges. And now they’re in jail.

For some of them, the answer might be Yes. Maybe if they had more people they trusted in their lives; maybe if they had a better connection with the counselor or doctor they saw that one time; maybe if their friends and family had more time and resources to seek help with and for them.

Then again, for some of them, the answer might be No, but for frustrating and sad reasons. Maybe their friends and family did everything they could to help them, but they didn’t want their aid. Maybe they became so fearful for their safety that they withdrew from everyone and, in isolation, their symptoms became worse. Maybe they believe that they are fine; it is the rest of the world that is confused and ill. Maybe their only experience with psychiatrists was involuntary hospitalization: Who wants anything to do with a system that takes away your rights and forces you to accept medication?

Some of these people are so young. To be clear, it’s troubling whenever someone of any age ends up in jail solely because of psychiatric symptoms. But can you imagine being 18, 19, or 20 years of age and landing in jail in the midst of hearing incessant, taunting voices, believing disturbing things that simply aren’t real, and having no visitors because the few people who are in your life are scared of you?

It’s heartbreaking.

At least these individuals come to clinical attention. And many get better: They form relationships; they talk with my colleagues and me; they learn how to get along with others; they reflect on what has happened and how to avoid similar consequences in the future; some take medication to help reduce their symptoms.

But then I think about all the people who never encounter law enforcement and never enter the criminal justice system, but they also experience significant symptoms. How do we prevent All of This for:

  • the man who doesn’t tell anyone any personal information and stuffs his tattered clothes with plastic bags to stay warm
  • the woman who won’t move indoors because she believes that the aliens will execute her if she does so
  • the woman who won’t leave her house because she believes her neighbors are cannibals
  • the man who sits all day on the sidewalk across the street from his old employer because he believes that he will get his job back

What about them? How do we help those individuals when the system ignores those who cannot or will not play by the rules?

Many mornings I see the same woman standing near a bus stop. The bus stop is covered, but she never stands underneath the awning. She stands behind the bus stop, even when it’s raining.

You can smell her—a mixture of sweat, dirty socks, and yeast—from several feet away. Pedestrians move around her the way water swirls away from large rocks on the riverbed.

Two black garbage bags sit at her feet. They are full. Plastic zip-lock bags poke out of one of them.

She is a young woman of color. She wears a dark hoodie that is too large for her slender frame, but it’s not zipped up all the way. She’s not wearing anything underneath the hoodie, not even a bra. An unwashed skirt smeared with dirt covers her legs. Her mangled sandals reveal that she has not clipped her toenails in many months.

She talks to an unseen audience and everyone can hear what she says. Her voice is rich and though her sentences do not make sense, she speaks with dignity.

The other morning the rain wasn’t the usual mist that falls from Seattle skies. The droplets were full and heavy, a shower of dark water as the sky was filling with grey light.

No one was standing in the bus shelter. Her clothes were already damp.

“Excuse me?” I asked. She had raised an arm to make a point in her discussion.

She fell silent and blinked a few times.

“Do you want to move so you’re under the bus shelter? So you won’t get wet?”

She turned her head and looked away.

“I can help you move your stuff. It’s raining pretty hard right now.”

She dropped her arm and turned her head further.

“What’s your name? My name is Maria.”

She glanced at me, raised her arm back up, and resumed speaking: “All in all, we must to the left….”

I stood there for a moment, waiting for a sign. None came. I walked away.