Category: Blogosphere

Categories
Blogosphere Education Medicine

Wanna Help Me with My Talk?

I’ve been invited to give a talk to psychiatry residents about “psychiatrists and social media” and my own experiences as an online physician.

Could you, fine reader, help me by telling me why you read the writings of physicians online?

This can include blogs, the 140-character musings on Twitter, blurbs on Facebook, or the myriad options now available.[1. I started writing online when “social media” wasn’t in the vernacular, there were only “weblogs”, and a 56 kbit/s dial-up modem was considered speedy. Now get off my lawn.]

For visual interest, post your response on Twitter, Facebook, or Ello so I may snag a screenshot for my talk. You can also send me an e-mail; just make it clear that I can share the content of your note.

Thank you for indulging me.

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
Blogosphere Medicine Observations

Fear and the Online Physician.

To follow up on my last post I had intended to write something that follows the style of an FAQ:

  • What if your patients read your blog?
  • What if your boss reads your blog?
  • What if your patients ask you for medical advice through your blog?

Fear underlies all of those questions, though, and it seemed to make more sense to address that fear.

If you are a physician and you are concerned about the vulnerability of having an online presence, what do you worry about? Do you worry that patients will learn to hate you? That your boss will find a reason to fire you? That random patients will “bother” you?[1. Why do some physicians worry that patients will find them online and “bother” them? What low opinions we must have of patients if we automatically assume that they will “bother” us! And what little faith we must have in ourselves to establish and maintain boundaries should that happen! And how grandiose we must be to believe that patients want to expend the time and energy to “bother” us!]

Would you do something on the internet that you wouldn’t do “in real life” as a physician?

All the people you interact with as a physician—your patients, your colleagues, that person who works in the system, but you see him only every few months—already have opinions about you. You build your reputation with the little things you do every day.

If you think patients are lazy, your behavior will reveal that belief. If you tell someone (a colleague! a friend! another patient!) that you think patients are lazy, that will eventually become common knowledge. If someone confronts you about that, you’ll manage it the way you manage it… and people will observe that, too.

Recording your belief on the internet that patients are lazy seems like a bad idea (because it is). Stuff stays online for a long time and people will find it. If that scares you, it should. But if you’re not doing things like that “in real life” now, why would you suddenly start doing that on the internet?

You might think that the lack of an online presence (or having an anonymous presence[2. It may be true that physicians, under cloaks of ostensible anonymity, can report and discuss problems in medicine with greater candor. Whistle-blowing can be a good and necessary thing. However, anonymity is ultimately short-sighted: It is difficult to maintain true anonymity on the internet. More importantly, if people know who you are, you have greater power and credibility to identify and solve problems.]) will protect you because if they can’t find you, they won’t talk about who you are, what you think, and what you do.

That’s not true. People already talk about you.[3. Yes, people are talking about you, but let’s be realistic: They don’t talk about you all the time. Or even all that often.]

And these are people who know what you look like, know where you work, and have experience interacting with you. Patients who don’t like you will continue to dislike you. They’ve probably told someone why they don’t like you. Who knows: They might’ve even shared their opinions about you on the internet. (As I have noted elsewhere: Having an online presence gives you the opportunity to shape your reputation on the internet. You already take active steps to shape your reputation “in real life”: Maybe you make a point of greeting everyone at work with a smile. Or overtly washing your hands in front of patients.)

The internet may be different medium, but the messages we send are the same. It’s also a place to learn and exchange ideas: What are other medical professionals learning? What do patients want? What problems are we trying to solve? How can we make things better? We’d like you to join the conversation.

As a physician you’re trained to discuss risks, benefits, and alternatives about interventions with patients. Having a presence online has its own risks and benefits. If you do decide to step into the online arena, know that you aren’t alone: There are many physicians who write on the internet. Join us.

Categories
Blogosphere Nonfiction Reflection

My Brief History on the Internet.

The first time I posted my writing on the internet was in 1997. I created a website about The Evolution of Mickey Mouse. It was based on a report I wrote in high school about the small mammal. My research for this report entailed several visits to the library to scroll through multiple rolls of microfilm (do kids these days even know what microfilm is?) to find articles that described the mouse during his heyday. I decided to put my findings on the internet so other people wouldn’t have to dig through canisters of microfilm. That Mickey Mouse website did well: For a short period of time, back when the Yahoo! search engine reigned supreme and Google was new, the site was ranked #2 with the search terms “Mickey Mouse”.[1. Disney.com, of course, came up first if you searched for “Mickey Mouse”.] Children from the world over sent me e-mails with instructions to “say hi” to Mickey Mouse. The internet was a sweet and innocent place.

My first blog was hosted on Open Diary. It was late 2000 and I was a medical student. I used a nom de plume that now causes me some mild embarrassment. I wanted to record my experiences in medical training. This was not a new practice for me: In junior high, high school, and college, I filled the college-ruled pages of dozens of spiral-bound notebooks with my thoughts. To my knowledge, there weren’t many medical students blogging at that time. Other Open Diary users read my writing, seemed to enjoy it, and expressed interest in what happens in medical school. Writing for an audience was fun. The internet was a social and friendly place.

Open Diary used fixed templates. While I knew that the substance of the writing was paramount, I wanted more style on the screen. That’s when I moved my writing to Blogger (still owned by Pyra Labs at that time) and adopted the title “intueri: to contemplate”. That would remain the name of my blog for six to seven years. I dropped my nom de plume and started using my first name. No one could figure out who I am with just my first name, right? And even if they do, who’s gonna care?

I wrote about my experiences in medical school… and then about my experiences in residency. My blog moved off of Blogger and I bought my own domain. I used MovableType for a few years. I then tried WordPress and have used it since. I read Instapundit and he posted an e-mail I sent to him. Ezra Klein, before he became Ezra Klein, called me “one of the web’s most graceful prose stylists“. I hosted Grand Rounds a few times.[2. If you know what Grand Rounds is, that shows your blogging age.] I started meeting people who read my writing online. The internet was a dynamic and exciting place.

I started feeling ambivalent about writing online. I closed down comments because anonymous people left statements like, “ALL PSYCHIATRISTS SHOULD DIE” and “YOU’RE A PSYCHIATRIST, YOU KILL CHILDREN”. A physician who wrote a blog under a pseudonym was revealed in court. I worried that my writing wasn’t fictitious enough, that maybe my stories weren’t purely coincidental. My mind generated catastrophes: Someone might read a story and think I was talking about them! They would sue me and I would lose my license! Other doctors would judge me! I would never recover! Even if I did, one of those commenters who hate psychiatrists would then kill me!

So I shut down that blog. The internet was a scary and dangerous place.

I moved to New York City. A man who was living there had been reading my blog for a few years. He suggested that we meet. We dated. We eventually got married in Central Park.

I couldn’t not write. Nearly two years had passed since I had posted any of my writing online. I decided to start another blog, though I did not want to write in fear. In White Ink revealed my full name. (Nothing bad happened.) The first post appeared there in 2010. The internet was not dangerous place, though not an innocent place, either. The internet was a place to learn.

I purchased this domain name, mariayang.org, that same year. Would you believe that it took nearly four years for me to build the courage to finally occupy the space?

Next time: Occasionally asked questions about blogging as a physician.

Categories
Blogosphere Medicine Nonfiction

The Sandwich Incident.

Originally written in 2004, back before electronic medical records were a thing, back before duty hour restrictions, back before “social media” was a catch phrase, back before KevinMD was “social media’s leading physician voice” (and how cheeky I was!).

I knew it was going to be long night when the sandwich fell.

It was an omen.

My medical student had kindly bought dinner for me, as I was unable to dash down to the cafeteria in time before its closure. She smiled and handed me the two plastic boxes: one held a pile of fries, the other, a grilled cheese sandwich.

This sandwich is glazed in rich butter and oozes warm, gooey cheese. The bread is just crisp on the outside but wonderfully doughy on the inside. It is the fatty food that allows the intern to run around the hospital all night.

All you need is lard.

While rushing upstairs to see a patient complaining of “ten out of ten” pain (who was falling asleep on me when I finally did see her), the plastic box holding the heavenly grilled cheese sandwich shifted ever so slightly on the box of fries. I watched the box lazily tumble to the ground and crack open, like a pristine egg releasing its golden yolk.

“Nooooooooo!” I mourned loudly. The box clattered to the ground and the sandwich – oh, that wonderful sandwich – flopped forward and landed on the hospital floor. That hospital floor teeming with VRE and MRSA and MDR Pseudomonas and other letter combinations that only hint at how filthy the floor really is.

The nursing staff and hospital visitors laughed at me as I bent over to pick up the lifeless sandwich. How I wanted to apply the five-second rule. How I wanted to sink my teeth into that joyously fatty sandwich. I had been daydreaming about this sandwich all day. I was salivating as I carried the box around for the past half hour, imagining how delicious and perfect that grilled cheese sandwich would be.

“I love you,” I lamented as I reluctantly dropped the sandwich into the trash can. The visitors looked on, wondering if I was just engaging in theatrics.

If they only knew.

And then the patients stumbled in one after another, three heading into the intensive care unit, their hearts beating very fast, their blood pressures either plummeting to the depths of lifelessness or rocketing towards explosive strokes. There was a lot of running around to collect supplies for lines, a lot of orders being written for things like vancomycin and imipenem and levofloxacin and vasopression and dopamine and packed red blood cells and normal saline bolus wide open and octreotide.

And the pages. “This patient just took off.” “Can you order the bronchoscopy for tomorrow?” “I felt a ball of tissue when I did that rectal exam.”

2:00am finally rolled around and I realized that I hadn’t written any of the admission notes of all of the patients I had admitted. And I still hadn’t eaten dinner. Since that glorious sandwich was now resting in peace in a trashcan.

And the things that ebbed from the pen early this morning! The realms of my dreamworld crossed over too easily to my waking state. My notes included fragments like

“and the hypocall team”

“was awake to go home”

which made complete sense when I wrote them, but lacked any continuity or relation to my patients when I finally jerked myself awake. In my sleepiness, I wrote about one patient’s swollen foot in reference to another patient’s swollen leg. Same side, at least. And I didn’t recognize this error until later on this morning.

And the things people said to me today:

“Rough night, huh?”

“You look like death warmed over.”

“You look terrible. I mean, really, you look like s#*%!”

Okay, admittedly, I did look pretty socked out today. The intensive care unit patients kept me hopping all morning long.

And so I’ve been awake for 35 consecutive hours now. I don’t know if last night was just a particularly challenging night – I mean, it was… for me, anyway – or if it’s just that time of year when all of the interns are starting to burn out. I was loudly cursing medicine sometime around 3:00am when I went up to the orthopedic surgery floor to steal food.

Because, again, of the incident with the sandwich.

I don’t think I’ve ever gone to bed this early before. But there’s a first time for everything.

Addendum: Perfect timing—”Sleepy Interns Committing Key Errors, Study Shows“, via Kevin, MD, who probably never made any errors as an intern.