Category: Education

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Consult-Liaison Education Medicine

Foundations.

I never did follow up here on the talk I gave to attorneys about “Psychiatry 101“. Teaching the foundations of any subject is both challenging and rewarding. It is also an excellent way to remind ourselves of the importance of the basics. Foundations anchor and guide us, particularly when we start getting lost in complex or unusual situations.

During my talk I review the definition of “mental disorder”.[1. I dislike the term “mental disorder”, primarily because of the stigma attached to it. The term focuses on what is wrong, not what is going well. We also get so caught up talking about “disorders” that we stop talking about “people”.] DSM-5 states that a mental disorder has two components:

  1. disturbance in cognition, emotion regulation, and/or behavior (the assumption is that pathology in the brain/mind manifests as this disturbance)[2. The underlying assumption that “disturbances” reflect pathology in the brain/mind is up for discussion, given that we don’t know if there is a distinction between the brain and the mind. The two seem related, but how they are related remains unclear. Furthermore, some people would argue that not all disturbances represent pathology. Context matters. People who choose not to eat during a hunger strike against the government are demonstrating a “disturbance” in behavior. Does that represent pathology?] AND
  2. the disturbance leads to distress OR impairment/disability

Both conditions must be met. However, the second criterion has two parts. This complicates the definition of a mental disorder. Distress does not equate to disability. People can experience low distress and high disability: Consider the person who has lost all his relationships and is unable to hold a job because he believes that he is the Messiah. People can also have high distress and low disability: Take someone grieving the loss of his spouse.

Symptoms help define diagnosis, and diagnosis guides treatment. Danger arises when psychiatrists treat symptoms without a clear diagnosis. An analogy: Say you are lost in a city. You call your friend to pick you up.

“Where are you?” your friend asks.

“I don’t know,” you respond.

“What street are you on?”

“Main Street.”

“Main Street and what?”

“Um… Main Street and Popcorn Alley.”

“Okay. Stay there are I’ll be there in about 15 minutes,” your friend says to your relief. You and your friend were able to define where you were located, which allowed your friend to figure out how to get from his house to Main Street and Popcorn Alley.

But what is the conversation went like this?

“Where are you?” your friend asks.

“I don’t know,” you respond.

“What street are you on?”

“I don’t know. The streets don’t have signs on them.”

“Okay. What do you see around you?”

“Uh… there’s a coffee shop on one corner and a sandwich shop on the other corner.”

“What else do you see?”

“Well, there’s a parking lot across the street.”

At best your friend would probably express gentle frustration with your lack of clarity: There are many coffee shops, sandwich shops, and parking lots in the city. How is he supposed to find you with such vague directions? At worst your friend would say, “Okay, I’ll find you,” and then hop into his car and drive around, looking for the triad of coffee shop, sandwich shop, and parking lot. The diagnosis (location) is unclear, so the treatment (picking you up) is also unclear (and frustrating and wasteful).

There is variability in how psychiatrists approach diagnosis of a “mental disorder”. The criterion of “disturbance in cognition, emotion regulation, and/or behavior” is often the easier of the two to determine: Most people would agree that people who cut themselves, refuse to eat, or feel so hopeless that they literally can’t get out of bed are experiencing a “disturbance”.

If the disturbance leads only to distress, but not disability, does that mean a mental disorder is present?

Here are several instances of disturbance AND distress WITHOUT disability:

  • hearing voices say unusual things to you
  • having self-doubts and feeling terrible following a breakup
  • suspecting others of sabotaging your work

If these things happen to you, does this mean you have a mental disorder? Maybe, but not necessarily.

Here are several instances of disturbance AND impairment WITHOUT distress:

  • hearing voices say that you are God and that you should touch everyone to bless them
  • having beliefs that you do not need to eat or drink to live; air alone will sustain you
  • suspecting others of sabotaging your work, so you stop going into the office, never talk to anyone, and don’t share any of your data (some distress is probably associated with this)

If these things happen to you, does this mean you have a mental disorder? The impairment component makes it more compelling that a disorder is present. (Why, yes, I know my bias is showing.)

If we do not exercise diligence in our diagnosis of a “mental disorder”, then we may suggest an intervention that is incorrect or insufficient. Even worse, the treatment may be unhelpful or harmful.

We work with our patients to discern whether a mental disorder is, in fact, present. Together we then clarify what the mental disorder is. Lastly, we survey possible interventions.

This is the value of returning to foundations.

Categories
Education Funding Policy Systems

Jail Costs versus Hospital Costs.

We received the State of Washington Voters’ Pamphlet in the mail today. One of the initiatives, I-1401, concerns “trafficking of animal species threatened with extinction”.

Have no fear: This post is unrelated to trafficking of animal species threatened with extinction.

The “Fiscal Impact Statement” includes a statement about jail costs (highlighted for emphasis):

jailcost

“No wonder why people with psychiatric conditions end up in jail!” I exclaimed. “It’s so much cheaper for them to be there!”

Information about hospital costs are public. This page shares inpatient hospital rates for people who have Medicaid insurance in August 2015. All the hospitals in Washington State are listed in the leftmost column. One of the columns has the title “Psych_ Per Diem”. That column tells you how much money each hospital is paid if a patient with Medicaid is admitted there for psychiatric reasons. First, you will note that hospitals are paid[1. Forgive the passive voice when I write “hospitals are paid”. In Washington, hospitals send bills for Medicaid patients to the state. The state pays the hospital bill. The state then turns around and sends a bill to the region that the patient “belongs” to. The region then pays that state bill. The region gets money to pay that bill from a mix of federal and state Medicaid dollars, which ultimately come from taxpayers. Confusing, right?] different amounts. That alone is fascinating—what accounts for that? who decides how much money each hospital will receive?

More to the point, it costs anywhere between $711.55 and $1788.93 per day for an adult with Medicaid to stay in a hospital. The average cost of incarceration in Washington is $88 per day. Thus, it is at least eight times cheaper for someone to stay in jail than in a psychiatric hospital.[2. This page shares inpatient hospital rates for people who don’t have any insurance. Note that the rates are lower compared to the Medicaid rates. They are nonetheless still much higher than the daily jail rate.]

On the one hand, the differences in cost aren’t surprising: Hospitals often have more staff, equipment, and services. On the other hand, we also know that jails are often the largest psychiatric hospitals in any given region. For example, in Seattle, the jail has about 120 psychiatric beds. The largest psychiatric hospital in Seattle has about 61 beds.

I really want to believe that no one intentionally designed the system this way. Surely no person or system could be so heinous and miserly to funnel people into jail instead of a psychiatric hospital. Right?

Right?

But, then the disgust kicks in: What if the costs were reversed? What if it cost $88 a day for someone to stay in a psychiatric hospital and $712 a day for someone to stay in a jail? Would we see as many people with psychiatric conditions in jail? Of course not.[3. To be clear, we should also help people stay out of psychiatric hospitals, too. Inpatient services should be available if people need them, but let’s focus on prevention and help people stay in their communities. Being in a hospital generally sucks.]

It shouldn’t be all about money, but when the cost differences are that big, money has undue weight. If we actually want to help people with psychiatric conditions, we must pay for services. Otherwise, we will only see more and more of them in jail.

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Education

Full Moons and Lunacy.

supermoon

Now that the supermoon has passed, here’s a reminder that there is scant evidence that full moons are associated with erratic, violent, or unusual behavior.

Dr. Chudler offers a brief summary of studies related to human behavior and full moons on his website and notes

Although most experiments fail to show a relationship between the phase of the moon and abnormal behavior, the belief in the “lunar effect” is still strong among many people.

Scientific American also published a piece about this a few years ago and concludes

… the lunar lunacy effect appears to be no better supported than is the idea that the moon is made of green cheese.

Categories
Consult-Liaison Education Medicine Observations Reflection

Pay It Forward.

Prior to starting medical school, I had no desire to work as a psychiatrist. I had a plan: I’d become an infectious disease physician[1. I studied microbiology and molecular genetics in college. My fondness for bacteria persists.] or an oncologist.

During my psychiatry rotation as a medical student I spent four weeks on a consult-liaison service. I worked with an attending who was smart and excellent with patients. Though everyone agreed he wasn’t warm, he was genuinely kind. (He also wore bow ties and suspenders. His clothes never had wrinkles in them. Was this due to his military background?) My plans started to change.[2. It wasn’t a single moment that made me abandon my original intention to go into internal medicine. I still remember the case, though, that tipped me to go into psychiatry: One of my patients on the medicine service was a firefighter who had suffered a significant bleed in his stomach. I was able to talk about the cells and chemistries in his blood, the risk factors that contributed to his condition, and what he could do in the future to prevent this from happening again. Yet, I couldn’t tell anyone anything about him as a person, how he came to have those risk factors, how he perceived those risk factors, and if he had any desire or intentions to change his behaviors so that he could prevent this form happening again.]

Before starting my psychiatry residency, I had no particular interest in working with people experiencing psychotic symptoms (e.g., hearing voices, holding firm beliefs that are not rooted in reality, etc.). I had a plan: I’d become a consult-liaison psychiatrist and spend my days in hospitals spanning the boundary between acute medical care and psychiatry. There was a little of everything in consult-liaison psychiatry: the full spectrum of psychiatric conditions; brief psychotherapy; teaching patients, families, and, often, the staff of the primary medical service; starting and stopping medications to reduce distressing symptoms.

During my residency I found myself finding the most meaning when providing care to people with limited means: refugees from Southeast Asian countries; military veterans with few supports upon their return from wars ranging from World War II to the wars in Iraq and Afghanistan; people living in homeless shelters or on the streets. Medications were not always useful or indicated. The senior residents and attendings in these settings were astute, unpretentious, compassionate, and just good with people. My plans started to change.

Now, as an attending, my interests are a mix of all those things: I like working with people with significant psychiatric symptoms who often have limited means. I like working in teams to help people get better and out of the system, whether that is the hospital, the jail, or the mental health system entirely.

I spent over eight years of medical training under the supervision of “attendings”. It took me a few years to get used to people calling me “Dr. Yang”.[3. I still find it jarring when colleagues who routinely call me “Maria” suddenly address me as “Dr. Yang”.] I guess I’m not yet used to the idea that I am now an attending and people expect me to “know”:

  • a high school student who wants to interview me to ask about my work as a psychiatrist
  • college students who want to learn more about non-traditional work in psychiatry[4. Thanks for helping to inspire this post, Anna!]
  • medical students who want to know which psychiatry residencies they should apply to if they want specific training in working with indigent populations
  • residents who want to know which fellowships they should apply to if they are interested in public sector clinical and administrative duties
  • fellows who want to know where they should apply for work in non-traditional settings

It’s weird. Impostor syndrome persists: These people think I’m qualified to tell them?

When I think about all the people who guided me—intentionally or not—to where I am today, I find that the second best way to thank them is to pay it forward.[5. The first best way to thank people, of course, is to directly thank them for the specific things they said or did.] We need people who have the will and energy to serve the community, who are willing to think about and do things differently. Yes, interests change, plans change, people change. However, we never know how our words and actions may inspire those around us.

Categories
Consult-Liaison Education Informal-curriculum Medicine Nonfiction Observations Reflection

Teaching Moment.

The Chief of Service ushered me into the room, but said nothing. His staff of fifteen looked at the Chief with expectation and, upon realizing that he was looking at me and probably wasn’t go to say anything—including my name or the reason for my visit—the fifteen people joined him in looking at me.

“Hi,” I said, taking the cue and flashing The Winning Smile. This is my name, this is my title, and this is why I’m here: As a psychiatrist, I think there is overlap in the work that we do and in the patients that we see—

“Is it okay if we refer to your patients as ‘wackos’?” the Chief blurted out. Nervous laughter twittered among his staff.

“I’d prefer that you didn’t.” My voice was light; my face was dark.

“Oh. I guess another psychiatrist should have told me that.” He was still smiling.

“I hope I’m not the first one to do so.” When he finally saw the lasers shooting from my eyes, his smile dissolved and he looked down.

There are several reasons why I believe that social skills are not his forte:

  • He either chose not to or did not think he needed to introduce me to his staff.
  • As a Chief of Service he should have known better than to say such things in front of his entire staff.
  • This exchange occurred within five minutes of us meeting each other.

I think his question—“Is it okay if we refer to your patients as ‘wackos’?”—was his honest effort to connect his staff and me together. Everyone would have a good laugh, we’d share something in common, and we could move forward with greater ease. He thought his comment was benign.

It makes me wonder, though: Had he made a similar comment in the past to another psychiatrist? And had that psychiatrist laughed? Did a ridiculous repartee follow?

Did another psychiatrist reinforce this sort of behavior?

He’s not a “schizophrenic”. He’s a guy with a diagnosis of schizophrenia. Maybe he’s even a guy who is skilled guitar player, a father of two children, and has a degree in political science who happens to have a diagnosis of schizophrenia.

She’s not a “brittle diabetic”. She’s a woman with a diagnosis of diabetes. Maybe she has a knack for training dogs, has a remarkable talent for singing, and was on her way to law school when she was first diagnosed with diabetes.

People are people with various interests, talents, and potentials. They are not their medical conditions.

No one is a “wacko”.

The Chief of Service sent me an e-mail later:

Thank you for visiting us and also for your gentle way of reminding me of my crudeness and insensitivity. I am sure you hear enough negative attitudes towards your clients that you would welcome the opportunity to create a more positive attitude towards mental health issues.

I actually don’t hear many “negative attitudes” about my patients. Perhaps this is because every moment can be a teaching moment and, over time, people learn not to use such language (at least around me). As I noted several years ago:

Doc­tors, like most peo­ple, often assign adjec­tives to patients because it can be hard to iden­tify and then acknowl­edge emo­tions. It is much eas­ier to say, “She is such a dif­fi­cult patient! She is never happy with her care!” than to say, “I feel angry and help­less when I see her because it seems like noth­ing improves her symp­toms!” Leav­ing out the sub­jec­tive “I” gives the illu­sion of objec­tiv­ity and professionalism.

I can only hope that the Chief of Service shared his reflection about his “crudeness and insensitivity” with his staff.