Category: Education

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Consult-Liaison Education Lessons Medicine Observations

Red Herring (II).

My patient was exhausted. She tried to drink the soup the nurses gave her, but said it tasted bad. She curled up on her right side and her eyelids drooped. I watched her fall asleep.

I wanted to talk with a doctor. Though I knew that it was unlikely she would die at that moment, I nonetheless worried that she would.

At least we were in an emergency room.

In an effort to “do something”, I brought my document to the clerks’ desk. Could you make a copy of this and put it in her medical chart?

“You have to give that to a doctor or a nurse and then they can give it to us.”

“No doctor has seen her yet and I might have to leave before she is seen. Can you please make a copy and put it in her chart? It has a lot of useful information that—”

“Listen, I can’t take that. You have to put the patient’s name and medical record number—”

“I have.” Anger made me speak louder. “I’m her psychiatrist. I have information that I want them to see. Can you please—”

“No. You have to give that to a doctor or a nurse—”

“Fine. Thank you.”

I don’t know why I thanked her. I wanted to yell at her, tell her that I was a doctor and she wasn’t. Didn’t she realize that, as a doctor, I might have some idea what the physicians would want to know? Could she only cling to a policy that made no sense in this situation?

But my condescension wouldn’t have helped my patient. So I bit my tongue and returned to her. She was still sleeping.

A voice announced over the intercom: “To help ensure that patients are seen in a timely fashion, we ask that all family members please leave the emergency room at this time.”

I did not budge. My patient would not be able to explain what had happened. I needed to speak to the doctors directly.

A security guard ambled over.

“Excuse me, miss, I have to ask you to leave.”

“My name is Dr. Yang and I am her doctor. I must speak to her physicians directly. She has not been seen yet.”

“She can talk to the physicians herself.”

“Actually, she can’t. I must speak to her physicians directly.”

“Why can’t she speak to herself? Is she mentally retarded or something?”

“No.” That’s none of your business.

“I’m sorry, but you’re—”

The security guard who saw me come in with the patient hours earlier passed by. I looked at him with hope.

“She’s fine. She can stay.”

“Thank you,” I said. Both guards walked away.

More time passed and no physicians were in sight. I began to think about quality improvement. What if hospitals implemented a system similar to that at the DMV, where you took a number and had some idea where you were in the queue? Why not build that into emergency rooms?

I knew why. Emergencies come in. People are seen out of order. And whenever staff saw the chart for my patient—“Woman with schizophrenia, weight loss in past year”—I knew that they would consider her a low priority.

Because, in many ways, she was. My patient wasn’t actively dying. She would not lose significant weight in the next few hours. Furthermore, she wasn’t making any noise. At this point, she was asleep, unperturbed by the cacophony in the emergency room. To everyone else, she was Not A Problem.

Though I wanted to believe otherwise, experience had taught me that when people saw a diagnosis of schizophrenia, they often did not take the patient’s—or my—concerns seriously.

(Part two of an ongoing series.)

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Consult-Liaison Education Lessons Medicine

Red Herring (I).

I sat in the emergency room and flipped through a magazine. I wasn’t actually reading; it was a way of distracting myself from all the noise.

Three hours had passed. No one had seen my patient yet.

The nurses, bless them, were kind to my patient. They brought her food and noticed that she was taking gigantic bites, but not swallowing any of it. The pocket of food in her cheek expanded and desperation stretched across her face.

“You don’t have to swallow it if you don’t want to,” I said, worried that she would inhale the food. “You can spit it out.”

A nurse saw us and grabbed some paper towels. “Here, spit that out. I’ll get you some soup. You look like you’re struggling to eat that.”

My patient obediently spit out the wad of food and looked relieved.

“Can you please document that in your notes?” I asked.

“Of course. I’m sorry that no one has seen her yet. Do you want another magazine?”

“No, I’m okay, thanks,” I said. She nonetheless returned a few minutes later with two magazines from last year.

Three hours earlier, I had shared a clipped account of her history to the triage nurse and she sent us to the medical side of the emergency room. I supported this decision, as I wanted my patient evaluated for medical concerns. That was the chief reason why I went with her. My patient would not be able to describe the problem. She’d say she was fine.

Upon learning that I was a doctor, the unit nurse pulled the emergency room attending physician away from a computer and asked me to talk to her. I immediately launched into my patter, summarizing why we were there.

I saw it happen and almost wanted to laugh: Her features hardened. The muscles that allowed any possible soft expression on her face tensed up. Her face showed nothing but muted anger.

“I don’t even know if I will see her. I’m going to go away now,” she said at me. As she was walking away, I heard her mutter, “Why didn’t she go to psych?”

During my entire time in the emergency room, she never came near us again.

My patient did not want to go to the emergency room.

“But we have to,” I said, trying to sound calm. I wished I didn’t feel as frantic as I did.

“I don’t want to go,” she said, literally hopping from one foot to another. She wrung her thin fingers together and fear overwhelmed her face. Those sunken temples seemed to sink further as she frowned.

“I know you don’t want to go, but we have to,” I said, pointing at the scale. “I said that you would have to go to the emergency room if your weight dropped below 100 pounds. Remember?”

“Yeah.”

“What is your weight today?”

“99 pounds.”

“And what did I say would happen if your weight dropped below 100 pounds?”

“I’d have to go to the hospital.”

“That’s why we’re going to the hospital.”

“But I don’t want to go to the hospital.”

“We’re going to the hospital. I’m coming with you.”

We sat next to each other in the back of the car.

“You’re coming with me, right?” she asked, her eyes looking abnormally large in her head.

“Yes. I am going to be with you until a doctor sees you. I want to talk to the doctors directly, too.”

I had written up a document that summarized pertinent information about her: name, birthdate, diagnoses, medications. I wrote down the details about how her weight had fluctuated over the past year, how she went to a different hospital just six months prior for the same reason. I wrote how she had needed two blood transfusions, how they had dropped a camera down her esophagus to look around for disease. Except for mild inflammation, everything was normal. I wrote that I had reduced her psychiatric medications; she didn’t need to take so many. I wrote that she was fine, that her psychiatric symptoms hadn’t changed in months. I shared my fears that her symptoms were due to medical reasons. I didn’t want the hospital staff to follow the red herring that was her psychiatric diagnosis.

Back in the emergency room, the nurse had asked her to take off only her shirt and put on the hospital gown. My patient peeled everything off with no shame. As she pulled herself onto the gurney, everyone saw her gaunt buttocks through the gown flap.

The hours passed. The emergency room was busy. More gurneys were pushed into the room and people were muttering, screaming, upset.

She looked at me. I smiled with my lips, but not my eyes. We continued to wait.

Part one of an ongoing series. Read more for

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Education Homelessness Informal-curriculum Lessons Medicine NYC Observations Policy PPOH

Supervision and Support.

To conclude a description of my previous job at PPOH in New York, let me tell you about Friday afternoons.

Every Friday afternoon, the staff psychiatrists met as a group for three hours.

Those three hours were important and valuable. During that time, a variety of activities occurred:

Case presentations. Different psychiatrists presented cases to solicit ideas and help. Hearing the thoughts of others provided fresh perspectives and helped us “think outside of the box”. Each psychiatrist had his specific strengths and this forum allowed us to access his expertise.

Example: Someone once presented a case about a woman who was refusing to accept treatment for a major medical problem. The psychiatrist had assessed her decisional capacity and it appeared intact. This meant that we—other doctors, her psychiatrist, other non-medical staff members—had to respect her wishes… and also watch her become more ill and eventually die. The psychiatrist who presented this case wanted to (1) ensure that his assessment of her decisional capacity was thorough, (2) learn how to manage the (often angry and frustrated) reactions of the other physicians and non-medical staff, (3) get ideas about how to coach the other physicians involved in the patient’s care when they wanted to do something and she refused, and (4) vent and get support from us, as managing his own reactions and the reactions of others was taxing.

Sometimes the case presentations were less complicated: How can I encourage this patient to try medication? Is there anything I can do to get this patient to stop asking for medication? Do you have any ideas as to how we can keep this guy out of the hospital?

Grand Rounds. Grand rounds refers to a lecture on a specific medical topic. It is often considered a “big event” (i.e. lots of people are invited or expected to go). In academic medical centers, someone well-known in the subject usually gives the lecture.

PPOH established a Grand Rounds committee[1. The PPOH Grand Rounds committee was comprised of two people: a senior PPOH psychiatrist and me, as we were both interested in medical education. If you would like me to speak at your Grand Rounds or provide other teaching, let me know.] to organize a series related to homelessness and mental health. Speakers with expertise on schizophrenia, common infections in the homeless, harm reduction, housing first, tobacco use and cessation, and other topics shared their knowledge with us.

These lectures were an essential part of continuing medical education. We need and want to learn so we can provide excellent care for our patients, particularly since there is a dearth of literature for this population.

Peer supervision/support. Every job has its challenges. In psychiatry, it is no different. Working with individuals who have significant mental health problems, homeless or not, can be stressful. Sometimes we feel anger towards patients. Sometimes we feel frustration with other psychiatrists or physicians. Sometimes we feel scared that we did something wrong. Sometimes we worry that our patients will die.

Much of psychiatric training uses the apprenticeship model. While in residency, we meet with “supervisors” (attending psychiatrists) on a regular basis. Supervisors provide coaching and guidance to help residents learn psychotherapy and prescribing practices. This is also where the informal curriculum is taught: Supervisors are essential in teaching (demonstrating) professionalism and attitudes. It is during supervision that we also learn to examine our own reactions to clinical encounters… and, oftentimes, our reactions tell us more about ourselves than about our patients.

I was deeply grateful for these weekly three-hour meetings. (I have since realized that this set-up is rare. No money is gained while physicians are meeting for supervision. Neither patients nor insurance companies are billed. From a financial standpoint, it is wasted time. However, I’d like to think that this investment in physicians ultimately provides benefits for patients. I don’t know if there is any data to support this, though I believe it is absolutely true.) The built-in network of peers gave me security: I knew I could trust them to help me become a better doctor.

Many medical students and residents feel embarrassed to ask questions. They might feel ashamed to say “I don’t know”. With time and experience, that shame goes away. It’s okay if you don’t know. What you do next is what matters: If you need help, ask for it. You will (re)learn something, you will take better care of your patients, and you can then help another doctor in the future.

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Education Lessons NYC Policy PPOH

Assertive Community Treatment.

While at PPOH, I spent two days a week working with an Assertive Community Treatment (ACT) team.

ACT is somewhat like a psychiatric hospital outside of a hospital. It is an evidence-based practice[1. From the New York State Office of Mental Health: “When comparing recipients before and after receiving ACT services, studies have shown ACT recipients experience greater reductions in psychiatric hospitalization rates, emergency room visits and higher levels of housing stability after receiving ACT services. Research has also shown that ACT is more satisfactory to recipients and their families and is no more expensive than other types of community-based care.”] that features a multidisciplinary team (social workers, psychologists, psychiatrists, nurses, case workers) that works with a small group of patients who often experience impairing psychiatric symptoms. It provides comprehensive and flexible psychiatric services. All of the care occurs in the community.

The ACT team I worked on was staffed with:

  • one program director (social worker)
  • one team leader (social worker)
  • one MICA (“mental illness and chemical addiction”) specialist (social worker)
  • one vocational specialist (social worker)
  • one entitlements specialist (almost-graduate from social work school)
  • two case workers (one who had recently earned a social work degree)
  • one registered nurse
  • one secretary (who did much more than clerical work)
  • two psychiatrists (our combined hours did not fill a full-time position)

During my time there, I provided care for about 35 patients. (The other psychiatrist provided care for the other 35 patients.) The staff to patient ratio is purposely kept low, as ACT is considered an intensive intervention.

Patients who are referred for ACT services must have been psychiatrically hospitalized (often involuntarily) at least four times in the past year. They often have multiple emergency room or mobile crisis visits. Other outpatient services have often failed or have been insufficient to prevent crises and hospitalizations.

Thus, a chief goal of ACT is to keep people out of the hospital.

The ACT model dictates that the team (as a whole) must make a total of at least six contacts with each client[2. There is a movement in mental health—and in other parts of medicine—to move away from the term “patient”. In this particular ACT setting, patients were called “clients”. Sometimes they are called “consumers”.] every month, preferably in the community. One of these visits should be a meeting with the psychiatrist. Some patients regularly came to the office for their visits. Others, however, could not or would not come in. We thus went out to them. (Hence the adjective “assertive”, which, in some cases, could be construed as “coercive”. More about coercion later.)

If I did not see patients in the office, I often saw them in their apartments. (Limits and boundaries do not blur, but they certainly shift. My experiences in these residential settings inspired this post. To be clear, there were a few individuals who I never met alone. I insisted they meet me outside or in the clinic. Some of this was due to their past behaviors; some of this was my gut instinct.) For those who did not feel comfortable meeting in their apartments, we met in lobbies, parks, or chatted during walks. (During my time on ACT, I came to value talking and walking as a therapeutic intervention.)

ACT was formerly deemed “long term care”; some patients have been on ACT teams for over a decade. (This is often due to repeated psychiatric hospitalizations despite ACT services.) Most of the patients had psychotic disorders (such as schizophrenia) and, surprisingly, many of them had actively involved family members. I suspect that this impacted who was referred to ACT; family members were often the ones bringing people to the hospital for care (versus calling the police, etc.) Most patients “graduate” from ACT within a few years: They stay out of the hospital, become more involved in the community, and no longer need that level of care.

I learned in this position that people with chronic psychotic disorders can get better. Their symptoms decrease. They learn how to temper their behavior so that they do not attract undue attention while out in the community. They set and reach personal goals, like earning high school and college degrees, securing employment, getting sober from alcohol and drugs, and taking care of their physical health. They stop smoking! Sometimes they need a lot of support and a number of years need to pass before things settle down, but people with diagnoses of schizophrenia are not doomed to a life of poverty and “low function”.[3. The public rarely hears about positive outcomes for people with schizophrenia. There is research that suggests that a significant number of people with diagnoses of schizophrenia either experience improvement or recovery of their condition. Anecdotally, I agree.]

I also learned the importance of seeing patients in their environments. So much of contemporary medicine now occurs outside of a person’s living situation. That is often appropriate and fair (e.g. patients shouldn’t undergo surgery in their own homes). Because of the intimate nature of medicine, meeting in a “third” location can help preserve privacy and security. However, we can learn so much about how people function (or do not function) when we see their living spaces. We also realize strengths that we would otherwise overlook. A neat home, a sack full of old prescription pills, vinyl records of classical music, papers all over the floor, photographs of friends and family, roaches climbing over dozens of empty cans of soda: All of that is information that doctors often never have.

It is amazing how people live their lives. It is remarkable how much people will tolerate. And it is humbling that people are willing to share their lives with you.

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Education Homelessness Informal-curriculum Observations Policy

Medicators.

Two recent events inspired this post:

1. My husband and I had dinner at Farestart, which is

… a culinary job training and placement program for homeless and disadvantaged individuals…. As members of [this] community are placed in housing, the need for job-training will play a critical role in ensuring the self-sustainability of these individuals.

While eating the tasty food and learning about the mission of Farestart, I reflected on my experiences working with the homeless. I have encountered them outside of the health care system, in emergency rooms and psychiatric hospitals, and in medical hospitals as a psychiatric consultant.

I realized that, as a group, psychiatrists are skilled at prescribing medications for the homeless. Unlike Farestart, however, we offer little to help the homeless help themselves.

2. Since starting my new job in Seattle, several patients have come to me with the chief complaint[1. “Chief complaint” is a medical phrase that refers to the reason why a patient has come to see a physician. It is not a sardonic comment.] of wanting to stop their psychiatric medication(s).

One of the greatest pleasures of my job is helping people taper off of their medication(s).[2. To be clear, there are instances when I actively discourage people from tapering off of their medications, as some people end up in psychiatric hospitals when they stop taking medications. A personal goal of mine is to help keep patients out of hospitals.] My colleagues and I have all seen patients who are taking large numbers of psychiatric medications for unclear or invalid reasons. There is also data to suggest that certain classes of people are more likely to receive psychiatric diagnoses that may not be valid, which results in prescriptions for medication that they don’t actually need.[3. African Americans are more likely to be diagnosed with schizophrenia. Anecdotally, I’ve worked with several African American patients with diagnoses of schizophrenia who were taking antipsychotic medications, though neither the diagnosis nor the medications seemed indicated. We gradually tapered off the antipsychotic medication and nothing happened. They were fine. Which makes me wonder.]

Some people eventually come off of all of their medications without incident. Some people significantly reduce the number of medications they take. And, unfortunately, a few people end up in the hospital during the tapers.

That never feels good.

I realized, again, that psychiatrists are skilled at prescribing medications, but we know little about stopping medications. (In my brief review of Pubmed, I found only one article that offers suggestions about stopping medications.) Furthermore, as a group, we lack the knowledge about treatments other than medications and psychotherapy.[4. Psychiatrists in private practice are more likely to offer both psychotherapy and medication services. Psychiatrists who work in medical centers often only provide medication services due to the institutions’ financial systems.]

Perhaps this is due to the belief that patients who come to see psychiatrists have already tried everything else. They have gone through trials of exercise, counseling, deep breathing, meditation, naturopathic medications, etc. Because none of that has been helpful, they come to see a psychiatrist as a last resort.

That could be true.

This may be a function of our training. Contemporary psychiatry, for better or for worse, follows the medical model. The medical model focuses on biological causes of illness and disease. Current medical treatments (i.e. medications) aim to correct the presumed underlying biological causes.[5. The underlying biological causes of psychiatric conditions remain unclear. Discussions about “chemical imbalances” are still hypotheses, not theories. Psychotropic medications are primarily empirical treatments.] Thus, psychiatrists end up prescribing medicine because that is what we were trained to do. Furthermore, patients often expect us to prescribe medication. (Like other human beings, psychiatrists sometimes feel the pull to “do something”, even though “doing nothing” may be the most prudent choice.)

Psychiatrists, often rightly so, have reputations as “medicators”. A friend of mine works as a psychiatrist in Canada. She came to the US for fellowship training. An administrator told her that her role in the American clinic was that of “the medicator”. My friend was horrified. Because of the funding system, Canadian psychiatrists routinely provide both medication management and psychotherapy services. She could not believe that her role would be limited to the prescription of medication.

“What? You believe in the biopsychosocial model? You think context matters?” the American fellowship cohort dryly commented.

If the knowledge and practice of psychiatrists is limited solely to medications, of course the general public will believe we are simply “medicators”. This is problematic, as we have incomplete knowledge of how psychotropic medications work. (All psychiatrists should read Healy’s The Antidepressant Era. Healy does not outright dismiss antidepressant medication, but he provides data that strongly argues that antidepressants are not as effective as the public believes.)

I cannot speak for all psychiatrists, but I believe most of us did not choose to enter this field to become “medicators”. Thankfully, many psychologists were involved in my education. I’d like to think that, as a result, I am less inclined to pursue medications as the sole mode of treatment. I must admit, though, that I am unfamiliar with the literature for non-pharmacological treatments. (I am familiar with the literature for housing as treatment…. but what is the evidence—or lack thereof—for exercise? meditation? diet changes?)