Categories
Homelessness Seattle Systems

Did You Nominate Me for Seattle Mag’s Community Service Award?

Hey, there’s a short blurb in Seattle Magazine about my work during the past two years:

Top Docs ’14: Community Service Award Winners

Scroll down to “The Bridge”. (If you want the source that “more than 60 percent of chronically homeless people in cities nationwide face lifelong mental health problems”, it’s here.)

Thank you to whoever nominated me! (Please tell me who you are.) It was an delightful surprise.

(In the meantime, I’m asking readers for help for post ideas on Facebook and Twitter. I welcome your suggestions.)

Categories
Lessons Observations Reflection

Length of Day.

The long, glorious days have arrived in Seattle. The sun rises shortly after 5am and sets after 9pm. We’ve savored the warmth of the sun on our faces; the sky has been more blue than grey in the past few weeks.

The tradeoff is that, in the winter, the days are short. The sun rises close to 8am and sets before 4:30pm. Furthermore, the pewter clouds and rain blot out the light of the sun. The days are dark.

These cycles, though, are predictable. We celebrate what light we have during those winter days as we step through puddles and under naked trees. During the summer, we relish the long days as we witness the alpenglow of the sleeping volcano, hike the verdant mountains, and squint at the sparkling waters of the sound.

Life is not predictable. We do not know if our lives will be like a day in December or June in Seattle. We only know the length of day after the sun sets, after someone dies.

When his mother died, my father followed the custom and wore a black braid around his left bicep.

“How long did you wear it for?”

“Ninety days.”

He gave me four pieces of black yarn. While on the plane I created an uneven braid with the yarn and wrapped it around a black armband. I will wear it until August 20th.

The thing about death and dying is that, even though you know it will happen, it’s still abrupt.

This is why it is vital that you say what you need to say and do what you need to do while you still can.

You don’t know when someone you love or care about will die. If you have stuff you need to tell someone—your apologies, your love, your hopes, your affection—tell them now.

We regret those things that we could have done, but, for whatever reason, chose not to. Regret sucks.

And even if you do say everything you need to say and do everything you need to do, know that it may still not be enough. For those that we love, we can never tell or show them enough how much we love them, how grateful we are for them, how much we want them to have happiness and peace. When they die, that ache of regret may still persist: You wish you could express your love to them one last time.

It will be too late.

I told my mother everything I wanted to say in the six months between the time of her diagnosis of cancer and her death. She took advantage of the time, too, and shared her hopes, fears, dreams, and wishes with me.

I thank her. And I miss her.

Categories
Blogosphere Medicine Observations Policy Systems

Why I Work at the Fringe.

This article is making the rounds among physicians on Twitter. Much of the information in the article, unfortunately, is accurate.

For some of the reasons stated there, I left the “traditional” health care system and pursued work at the “fringe”.

Part of this is due to my clinical interests: I like working at the intersections of different fields. For example, I like the intersection of psychiatry and hospital medicine, which is called psychosomatic medicine. Another example is my interest in public psychiatry, which focuses on the intersection of social factors and mental health (e.g., individuals with psychiatric and substance use conditions in the context of homelessness and poverty).[1. Really, though, all of medicine could be “psychosomatic medicine” or “public psychiatry”; the divisions between mind, body, and environment are arbitrary.]

Part of this, though, was my sense that the system would not let me be the kind of doctor I want to be.

For a brief period I worked in a clinic where I had slots for four new intakes a day (60 minutes each) and 15-minute follow-up appointments for the rest of the day. If my schedule was completely filled with follow-up appointments, I could have seen up to 34 patients a day. (I never got to this point because I quit well before my panel got full.)

In reality, the 15-minute appointments were 12-minute appointments. I needed about three minutes to type out some notes to myself for clinical documentation.[2. I don’t like typing my note while I am seeing a patient. I’m not fully attending to either one when I do that.]

Because I was building a new practice, people with a wide variety of conditions and concerns came to see me. I was advised to refer patients out of the medical center who were “too sick”. This included individuals who were frequently in and out of psychiatric hospitals, had significant psychiatric symptoms, or otherwise had other stressors in their lives that made them “difficult“.

In other words, they told me to refer out the people who needed specialist care the most.

The reality, too, was that no psychiatrist could provide quality care to these individuals in 12 minutes. Imagine someone with depression so severe that he lacks the energy or interest to share his current distress with you. Or someone who is psychotic and insists that her ex-husband is tracking her through all the electronics in her home. Or someone who is so anxious about leaving his house that his attendance to the clinic is worthy of celebration.

Obtaining an accurate history guides diagnosis, which then guides treatment. An insufficient history can thus lead to haphazard interventions. You can see how the 15-minute appointment model results in heavy reliance upon (potentially unnecessary) medications. If someone says he feels depressed, it’s difficult to validate his emotional experience, provide education about his condition and non-pharmacological ways to manage it (e.g., behavioral activation, sleep hygiene, etc.), and have a discussion about medications, which should always include risks, benefits, and alternatives, in 12 minutes.

It is much easier to write a script and ask someone to return in a month. (This inspired my post about the Automated Psychiatrist Machine.)

Furthermore, this clinic was in a medical center with a group of primary care physicians. Primary care doctors referred their patients with diagnoses of schizophrenia and bipolar disorder to the psychiatry clinic (as they should). These individuals, however, were “too sick”. Never mind that, unlike the primary care physicians, we psychiatrists had the training to diagnose, treat, and manage these individuals with significant psychiatric conditions.

Thus, these patients often returned to their poor primary care physicians, who tried to care for them the best they could… which often entailed medication regimens that were unnecessary. (Primary care physicians deserve no blame for this: How are they supposed to know?)

This clinic also “rewarded” psychiatrists for “productivity”. The more patients a psychiatrist saw, the more money the psychiatrist would earn. This led to “cherry-picking” patients. Psychiatrists would keep patients who either had minor conditions or symptoms that had resolved, because those are the patients you can adequately see in 12 minutes. As a consequence, patients with more debilitating symptoms could not access the clinic. The psychiatrists had no incentives in either time or money to send these “cherry-picked” patients back to their primary care doctors.

My frustration and disillusionment compelled me to leave the job. I returned to positions at the “fringe” to work with patients who often are also not part of the system or patients that the system had failed. Consider the man who has been homeless for the past ten years and is too paranoid to access any health care service. Or the woman who was beaten and molested as a child, sent to foster care and group homes, never completed high school, “aged out” of youth care, and now has no resources or support.

I couldn’t wait for the system to change, so I sought out settings where both my skills would be useful and I could be the kind of doctor I want to be. There may not be many physician jobs at the “fringe” and certainly not all physicians want to work there. When we physicians vote with our feet, though, we show what we value, the kind of care patients deserve, and how the system must change.

Categories
Consult-Liaison Education Medicine Reading

DSM-5: Malingering.

My DSM-5 group has lost its previous vitality for the same reasons my blog has lost its previous verve (pending job change, ongoing family health concerns). But! The DSM-5 group has had a few updates; the most recent edition is below. If you’re interested in subscribing to the DSM-5 e-mail group, you can sign up here.

Malingering in DSM-5, like in DSM-IV, is a “V code”. “V codes” (in ICD-9) will turn into “Z codes” (in ICD-10) and these are considered “other conditions that may be a focus on clinical attention”. This means two things:

(1) Conditions listed as “V codes” are not diagnoses because

(2) Conditions listed as “V codes” are not mental disorders.

Therefore, malingering is not a mental disorder.

In crass terms, malingering means that people are faking or *really* embellishing physical or psychological symptoms. People who are malingering do this “consciously” (hat tip to the analysts) because there is an external incentive to do so. These external incentives might include:

a) avoiding military duty
b) avoiding work
c) obtaining financial compensation
d) evading criminal prosecution
e) obtaining drugs

Malingering can be hugely adaptive: If you were homeless and the temperatures outside are below freezing and a winter wind is whipping the frost off of the trees and there are no open shelter beds and you are hungry because the last time you ate was two days ago and that was a soggy, half-eaten sandwich you found in the trashcan–

–wouldn’t you consider going to the hospital and say that you want to kill yourself so you could be in a warm place for a few hours and get some non-soggy food?

DSM-5 argues that if “any combination” of the following four items is present in a patient, you should consider the condition of malingering:

(1) Medicolegal context of presentation (a lawyer sends the client for evaluation or the patient presents for care in the midst of criminal charges)

(2) There is a “marked discrepancy” between the individual’s “claimed stress or disability” and “objective findings and observations”

(3) “Lack of cooperation during the diagnostic evaluation and in complying with the prescribed treatment regimen” (some tired clinicians would summarize this as “a difficult patient”, though I much prefer DSM-5’s description)

(4) The presence of antisocial personality disorder

I applaud DSM-5’s efforts in keeping the description of malingering neutral. Some people have strong reactions towards (translation: self-righteous fury at) people who present with malingering. Keeping the focus on the behaviors helps temper the emotional reactions.

DSM-5 then clarifies the differences between malingering and factitious disorder, conversion disorder, and related conditions. Malingering is the only condition here where symptoms appear solely because there is an external incentive.

On a somewhat related note, the condition that follows malingering in DSM-5 is “wandering associated with a mental disorder”. This is apparently limited to walking (where the “desire to walk about leads to significant clinical management or safety concerns”).

The next post will hopefully show up less than one month away.

Categories
Homelessness Observations

All Four Seasons.

Green leaves are budding from the trees lining the city streets. The branches sway from the weight of small birds, their throats full of song. The chill in the morning air melts away as the Spring sun warms the ground, beckoning the flowers to push through the damp earth. Pedestrians carry their umbrellas and weave around the puddles on the sidewalk.

Some of them do not see the soiled sneakers poking out from under the bundle of blankets heaped in the shop doorway. Some people cast a sideways glance and say nothing. They have places to go.

People turn the calendar pages and begin to wear white again as Summer breezes into the city. The air is thick with moisture and the asphalt radiates the heat of the sun. When shop doors open and the cool conditioned air whooshes outside, people wearing strappy sandals, twill shorts, and thin tank tops sigh with relief. Fireworks light up the sky, people have picnics in the park, and the kids catch fireflies at night.

The bundles of blankets have moved underneath the bridges and along the banks of the river. The shop owners, taking advantage of the longer hours of the season, throw away the flattened cardboard boxes they find near their doorways. These are entryways, not platforms for beds.

The arc of the sun shortens and fog begins to drift into the city. The once verdant trees now don red, orange, and yellow leaves. The Autumn rain begins to fall. Kids pile into school buses and adults board the train, all daydreaming about their summer adventures.

The bundle of blankets appear downtown again. The blankets get wet from the frost in the woods. Rectangles of cardboard, piles of blankets, and rolling suitcases collect under the awnings of buildings.

Old man Winter hobbles into town. Freezing rain and snow fall from the pewter sky. People hurry to the store to stock up on toilet paper, bread, milk, and canned food. Their breath turns to white mist as they mutter about the cold and prepare for several feet of snow. Smoke floats out of chimneys, readers snuggle with books, and the kettles whistle when the water boils.

The bundles of blankets poke out of cardboard forts dressed with tarps or garbage bags. The snow is already collecting on the corrugated roofs, which sag from the wet weight.

“If you see someone in need during the storm,” the newscasters say, “if you see someone who is homeless, call this phone number.”

The homeless are there all the time. They are there all four seasons.