Categories
Homelessness Observations Reflection

Continuity of Care.

The first time I saw him he was walking around the shelter with another man. His hands were buried in the pockets of his hoodie and his gaze was fixed on the ground. He looked shorter than his actual height because he was slouching.

He and the man walked laps around the shelter while they talked. His expression was hard: Eyebrows furrowed, jaw tight, lips curled into a slight frown. He moved across the tiled floor like a sleek fish gliding through the water.

“Hi,” I said, introducing myself. “Do you mind if we talk for a few minutes?”

His companion kept walking as he coasted to a halt. His stony expression softened; his eyebrows raised and wrinkles appeared at the outer corners of his eyes as he smiled.

“Sure. Thank you.”

He and I walked laps around the shelter for the next few days. His father beat his mother, his brother, and him. At the age of 11 he found his mother’s body after she committed suicide. His father disappeared for days at a time. When he returned, his speech was slurred, clothes were dirty, and exhalations were thick with malt liquor. He stopped attending school. He ran away from home. He slept in alleys and underneath bridges. The police picked him up on a variety of charges: Theft. Drug possession. Criminal trespass.

The second time I saw him he lying on a mat in the shelter. The stiff blanket was not long enough to cover his entire body; his feet with their long toenails poked out.

He pulled the blanket off of his face and replied, “Heroin. Couple days ago.” Pulling up a sleeve, he showed me the collection of tiny bruises on his arm. He closed his eyes. Beads of sweat collected on the pale skin of his forehead.

“I’ll be done kicking dope tomorrow.” He pulled the blanket back over his head.

The third time I saw him he was sitting on the floor in the shelter, his arms hugging his knees.

“I don’t make many promises. I promised her that I won’t kill myself. I keep the promises I make, so I didn’t do it. I really wanted to.”

He accepted the invitation and got up. He and I walked laps around the shelter. He had yet to talk with her, though he planned to see her tomorrow. The last time he used heroin was over six months ago, but he was also in jail for four of those months.

“You didn’t use anything in jail?”

He shook his head.

After a pause, he said, “You know, I’ve seen you downtown. You were with a guy, so I didn’t want to bug you.”

“Is that where you’re staying these days?”

“Yeah.”

“Outside?”

“Yeah.”

The fourth time I saw him he was standing on the sidewalk outside of a methadone clinic. The hood of his sweatshirt was pulled over his head and baggy jeans covered his long legs. His hands were buried in the pockets of his sweatshirt. The other man made a joke; he chuckled and wrinkles appeared at the outer corners of his eyes as he smiled.

I crossed the street. He was with a guy and I didn’t want to bug him.

The fifth time I saw him he had already passed me. Without realizing that I was reviving an old habit, I wrapped the long white coat closed as I looked over my shoulder.

“Smith!” the officer barked. “Stay where you are. Turn around.”

He stopped, turned, and looked up. We saw each other.

“Go back to your cellblock, Smith.”

He moved across the concrete floor like a sleek fish gliding through the water. Before he passed me, he nodded in recognition. I nodded back.

We both kept walking. I sighed.

Categories
Education Medicine Observations Policy Seattle Systems

A Primer on Psychiatric Boarding.

The Washington State Supreme Court recently stated that “psychiatric boarding” is unconstitutional.[1. You can read the court’s opinion here. It’s a fairly easy read.] I agree with and support the court’s decision. “Boarding” is a terrible practice.

To be clear, though, the consequences of this decision may be undesirable.

Some background: In the state of Washington, the only people who can hospitalize individuals against their will for psychiatric reasons are “designated mental health professionals” (DMHPs). Police officers can bring people to emergency rooms against their wills and physicians and other professionals can evaluate people who show distress. A DMHP, as an agent of the state, makes the ultimate decision whether to detain someone against his will.

Let’s be clear about this: Being hospitalized against your will is stressful, upsetting, and frightening. The state is taking away the rights and freedoms from an individual. Civil liberties? Gone. It is a big deal. No one enjoys the process.

In order for a DMHP to hospitalize someone against his will, a person first must show evidence of a “mental disorder”.[2. A finer point about “showing evidence of a mental disorder” is that there should be some proof that hospitalization is an effective treatment for the mental disorder in question. This is why some people go to jail and not to the hospital. This path can lead us into the weeds.] Having a mental disorder alone, however, is not reason enough to hospitalize someone against his will. At least one of the following three criteria must also apply:

  • He is a danger to himself. (Consider a man with major depression who was found nearly unconscious; a noose made of bedsheets was around his neck.)
  • He is a danger to others. (Consider the woman who is walking across the highway multiple times because she believes that God wants her to proselytize to the drivers.)
  • He shows “grave disability”, or is unable to meet his basic needs. (Consider the man who has not eaten any food in nearly two weeks because he believes that all food is actually composed of his internal organs.)[3. If you think that none of these scenarios ever really happen, I encourage you to go volunteer at your local emergency room.]

Thus, at least two people–the person who wanted the individual to go to the hospital and the DMHP–were concerned enough about the individual to believe that he needed to be in the hospital to get care.[4. For now, let us put aside arguments that psychiatric hospitalization is never helpful or indicated. Some people believe that psychiatric hospitalization is a veiled form of incarceration.]

That “to get care” part is the crucial point when we talk about “boarding”.

People who are involuntarily detained in Washington are only allowed to be hospitalized in certain facilities (or certain beds). Facilities submit an application to the state to become a “certified” place where they can treat people who are hospitalized against their wills.[5. Indeed, there are psychiatric hospitals in Washington State that are not certified to treat people who are hospitalized against their wills.] These places can be entire buildings (called “evaluation and treatment facilities”, or “E&Ts”, here). They can also be specific beds within a hospital, usually on psychiatric wards.

There has been concern if “inpatient psychiatric capacity is sufficient to meet [a] potential increased demand” for involuntary hospitalizations. All certified beds are frequently occupied. Most people who are referred for involuntary hospitalization are not in psychiatric hospitals; they are in hospital emergency rooms.

There are medical centers (and, by extension, hospital emergency rooms) in Washington State that do not have any psychiatric providers on staff.

Thus, DMHPs have been hospitalizing people against their wills, but no certified treatment beds are available. These detained individuals therefore are admitted to hospital emergency rooms or random hospital wards while they wait for certified beds to open up.

If the hospital does not have psychiatric providers on staff, that means these detained individuals don’t receive any psychiatric care. People could wait hours, days, or even weeks before they are transferred to a certified facility to receive formal psychiatric services.

In the meantime, these individuals are often physically restrained to their beds. There might not be enough hospital staff to fulfill the state’s mandate that they remain in the hospital against their wills.

Sometimes these individuals receive doses of sedating medication for multiple days in a row. (Imagine you work in an emergency department. Someone who is detained in your emergency department will not stop screaming obscenities at other patients. He also tries to spit at everyone. He has also tries to punch the nurses whenever they walk by.)

This isn’t treatment. (Remember, the state ordered that this person be hospitalized against his will to get care.)

Thus, you can now see why the state supreme court decreed that it is not okay to “board” psychiatric patients. People who are detained against their will, by the state’s definition, need treatment. “Boarding” isn’t treatment.

This is why I agree with and support the court’s decision.

However, now that you know that there aren’t enough certified psychiatric beds in the state, you can guess what undesirable consequences might come from this decision.

The detained individual in the emergency room who yells and tries to punch all the nurses? Now he might end up in jail on charges of assault. Jail is not a therapeutic environment. Some jails do not offer any psychiatric services. Incarceration, like boarding, is not treatment.

Detained individuals might instead be released into the community if no certified beds are available at that time. Someone else–another police officer, another family member–might try to re-refer them back to the hospital a few hours after they were released. This results in a cycle in and out of hospitals and other institutions. That isn’t treatment, either.

Hospitals that have certified beds may feel pressure to discharge people more quickly due to the heightened demand. These individuals may not have recovered “enough” and may return to the hospital much sooner than anyone would like.

Another potential consequence is that those individuals who seek hospital services on their own–perhaps in an effort to avoid involuntary hospitalization–may not be able to get into a hospital at all. Those detained against their wills may occupy all of the certified hospital beds.

My understanding is that the state is considering various ways to work with the new law: This includes increasing the number of certified beds, creating different options to divert people from hospitals, and reducing the amount of referrals for involuntary hospitalization.

I don’t understand why some hospitals don’t employ psychiatrists.[6. Psychiatric services are not “revenue generators”, so I suspect this is the reason why some hospitals don’t hire psychiatrists.] If a pregnant woman about to have a baby shows up at an emergency room, hospitals have staff available with the expertise to manage her care.

Why isn’t this the case with psychiatry?

Categories
Lessons Nonfiction Observations Reflection

The Club.

Though you are now a member of the club, you don’t know it.

It feels like no one understands and that you’re alone. The memory of what happened to The Person You Love is heartbreaking.

The feeling seems endless. Perhaps you feel it in your body; maybe it feels like a hollow weight in your chest. Maybe your head feels heavy. Maybe most of it unfolds through your thoughts: You hear good news and your heart floats for a few moments, but then you remember what happened. Even good news somehow seems sad.

Sometimes it feels like time doesn’t move the way it did before it happened. Thoughts like, “This is the youngest I will ever be… will I remember this?” become regular visitors to your mind. You grasp those little things that bring you joy and cling to them:

  • The summer watermelon is cool, crisp, and sweet against your tongue. Will this be the last watermelon I ever eat?
  • How wonderful it is to see the splashes of peach, pink, orange, and purple across the evening sky! Will this be the last time I witness this supernatural work of art?
  • He has a delightful laugh! I hope that this won’t be the last time I hear it.

Life takes on a quiet desperation.

Because you don’t know if you will experience these moments again, gratitude overwhelms you:

  • I turn on the faucet and hot water comes out in seconds! I get to take a comfortable shower every day!
  • I have a place to live! My mind doesn’t have to spend every waking moment worrying about where I will sleep tonight!
  • I have friends! We talk, we laugh, we spend time together, we enjoy ourselves!

Life is beautiful and sublime.

You dream about The Person: Sometimes the dreams are comforting, sometimes they are disturbing, but they are all cryptic. You wake up, your limbs heavy in bed, and wonder: Is she really dead?

That feeling comes back. You know the answer to that question. She is, but you’re not, so you get out of bed.

There are moments throughout the day when you do forget what happened. The weight disappears and you focus on the things in front of you right now. Things shift, and your mind begins to make associations that you didn’t make before:

“I look at grass and I think of tombstones now.”

You concoct explanations to comfort yourself, though sometimes they don’t:

  • Molecules of air that were in her lungs are still in the house. When I inhale, some of that air is now in me.
  • Though she is dead, her genes live on in me. The genes continue to experience the world, even if she does not.

Some things don’t matter anymore. Kindness becomes essential. Relationships with people become vital.

When people in the club learn that you are a new member, they welcome you with a grace that you didn’t realize existed. You acknowledge that you had no idea that they were a member of the club.

“That’s how it works,” they reply.

They spend time with you. They share wise words. They share wise silence. They comfort you.

You then realize that you’re not alone, that there are people who understand. They appreciate how heavy the weight is in your chest and help you carry it. They remember the difficulty and loneliness of having to carry the weight alone. They also know that, ultimately, you often must carry it by yourself.

Everyone eventually joins this club. If you, too, are a new member, know that you are not alone. There is no club uniform, badge, or pin, but we are here and share your grief.

Categories
Lessons Medicine Observations

Four Adages.

Four adages I learned in medical training that I still speak of today:

“Common things are common.” (The alternate version of this that might have more appeal to zoologists: “When you hear hoofbeats, think horses, not zebras.”)

This cautions physicians to remember that it is more likely that the patient has a common condition than a rare one. Although it is prudent to consider all the possible diagnoses that might match a given clinical presentation, one should not seek confirmation for an exotic condition first.

Urinary tract infections are more common than bladder cancers. High blood pressure is more common than pheochromocytomas.[1. A pheochromocytoma is a rare tumor of the adrenal gland, which is a small lump of tissue that sits above the kidneys.]

Once you’re sure that there are no horses present, though, then begin the search for other ungulates.

“Treat the patient, not the number.”

This is a reminder that physicians should treat the person, not lab results.

If a patient’s blood count is a little low, but she’s not experiencing any symptoms, then do nothing. If someone’s lithium level has been low for months, but they haven’t had any mood symptoms, then don’t increase the dose of lithium.

This, however, does not apply to all conditions: People with alarming blood pressure numbers often feel fine. Same thing with high blood sugar numbers.

“The longer someone stays in the hospital, the longer he stays in the hospital.”

Hospitals are not sanitary places. The longer a patient stays in the hospital, the more likely he will develop an infection that is resistant to multiple antibiotics. This leads to complications that lengthens the hospital stay.

This also applies to staff: The longer a physician stays in the hospital (beyond her shift, for example), more things will come up that she will have to address, which will will keep her there even longer.

“When you only have a hammer, everything is a nail.”

This is a reminder to consider other perspectives. It is also an exhortation to recruit the minds and skills of others.

If the psychiatrist only knows how to prescribe medications, then all of his patients will receive pills. The surgeon might believe that cutting out the offending tissue is the only solution.

One wonders when these phrases first came into being. It’s an oral history that physicians pass along every July.

Categories
Education Informal-curriculum Lessons Medicine Observations Reflection

Guiding Principles for Medical School.

Dear Jane:

Thank you for asking me about my perspectives on medical school. Here are some general principles that you might find useful in your own training:

View everyone as your teacher.

Everyone you encounter will teach you something. Be open to what they have to offer.

Yes, your professors and attendings, the “official” teachers, will educate you. Patients, however, will often be your best teachers. Listen to what they say, watch how they react to what you do, and acknowledge and accept the feedback they give to you. Their teachings are often the most useful and valuable.

You might see a physician condescending to a patient and decide that you never want to do that. You might see a nurse offer quiet comfort to a patient and decide that you want to mimic that manner. You might witness a technician help a patient feel less anxious before a procedure and decide that you will steal that technique. You might talk to a physician on the phone and decide that you will adopt that professional and kind manner when you talk to other physicians.

In this way you can be a student for life.

Reflect on your experiences every day.

This can take many forms: You can keep a journal. You can talk with friends. You can meditate. You can go for a ten-minute walk around your neighborhood. You can sit in a chair and stare out the window. It doesn’t have to be a big thing.

Reflecting on your experiences will help consolidate what you learn so you can apply that knowledge in the future. This applies to “book” knowledge (physiology, pharmacology, etc.) and “non-book knowledge” (how to redirect a patient or your colleague, how to manage your emotions in the face of disease and death, etc.).

There will be times when you will feel overwhelmed and cannot or choose not to reflect. That’s okay. It happens.

You will see terrible things.

You will see people suffer. You will see people die. You will hear hospital staff say derogatory things about patients. You will see your colleagues lie about things they should not lie about. You will see everyone—the patient, nurses, doctors, technicians, family members—work as hard as they can and none of it will help the patient. You will see people who need help, but don’t want it.

Remember the discomfort you feel when you see things you don’t like. These experiences are your teachers, too. They will help you stay human and humane. Medical training can steal that from us.

You will do terrible things.

You yourself will do things you will not like. (Hopefully infrequently.) You will snap at patients. You will be snarky to staff. You will bend the truth, if not lie, because you won’t know what else to do.

You must reflect on these events so they don’t become habits.

Connect with physicians who do not work in academic centers.

Some physicians in the community will have practice patterns and work in systems that will appall you. Some will inspire you. While academic medicine does happen in the “real world”, it’s often different from what is in the community.

Exposing yourself to the non-academic world will help you learn about a greater variety of patients, creative and innovative developments in health care, and provide more context about medical care in the world. Even if you end up working in an academic center, these experiences will shape your practice.

After you decide what kind of doctor you want to be, take rotations in every other specialty.

Medicine is compartmentalized, but people are not. Your patient with high blood pressure may become pregnant… develop a painless red eye… fracture a bone… have her gall bladder taken out… or develop an alcohol problem. Learning about a variety of conditions will help you take care of people, not just diseases.

The most useful guiding principle for me during my training (and now) is to remember that your work is to take care of the patient. It’s not about the letters after your name, long titles, or how big your salary is. Medicine isn’t about you. It’s about the patient. That attitude will keep you humble, curious, and grateful.

Congratulations on your admission to medical school! May you find the work rewarding and meaningful.