Category: Education

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Education Informal-curriculum Medicine Reflection

Some Thank Yous.

To the intern on the trauma surgery service when I was a medical student: Thanks for occasionally wearing leather pants to work. Thanks for smiling and having a sense of humor despite having to round on thirty patients. Thanks for teaching us medical students while running a significant sleep deficit.

To the internal medicine resident who wanted to become a cardiologist: Thank you for indulging me and telling me how you dealt with the stress of medical training: You became still and tried to hear your heartbeat. When everything else seemed out of control, you focused on the steady rhythm emanating from your chest. That’s still something I do from time to time.

To the family practice physician who worked in the suburbs: I still don’t understand why you thought it was okay to pour liquid nitrogen on my head in front of the patient after you frosted the warts off of her feet. I mean, I do understand—you had power! I had none! what an amusement for you!—and thank you for showing me what a professional should never do.

To the surgical tech who was shaving the pubic hair off of a woman who was already under anesthesia: I don’t know why you and I were the only ones in the operating room. You knew I was there. As you were shaving her groin, you said, “You’re a fat bitch. You are such an ugly, fat bitch. I hate that I have to shave your fat ass.” She may not have heard you, but I did. As a medical student, I was too scared to tell you to stop. Thank you for showing me your cowardice and cruelty, as there are, unfortunately, others like you in medicine. I have since learned to speak up when people say violent things.

To two of my fellow interns: You stand out in my memory from that year. (One now works as a senior medical officer for a public health district in New Zealand; the other works in emergency medicine in an academic medical center in Texas.) We were brand new doctors running around the hospital and had no idea what we were doing. Do first, think later! I admired both of you for your intelligence and am grateful that we worked well together. I remember how you offered to help me when I was buried with neverending work. What I remember most, though, is how you made me laugh. When things were terrible—when the disease, dying, and death was crushing—you helped me smile when there was nothing else we could do.

To one of my medical students when I was an intern: Thank you for taking the time to write a letter to my residency director to express praise for my teaching abilities. You were both precocious and earnest: “I should know what a good teacher is, since I’m a medical student and many people teach me….” I hope you continue to write letters to those teachers who helped you grow.

To the male psychiatrist who took me to see a patient in a post-surgical setting: Thank you for teaching me who benefits from the questions we ask. We had just met her; she was weeping and told us she was uncomfortable. Out of nowhere you asked her if she experienced sexual abuse as a child. She answered yes. You then ended the interview and, while we were walking away, said to me, “I knew from her behavior that she was sexually abused as a kid.” I learned that I should never ask people questions just to show off.

To a female VA attending psychiatrist: Thank you for your enthusiasm for Cole Haan shoes. You were always so well-groomed—I imagine you still are—and your delight for shoes showed me that even sharp, warm attending physicians get excited when expensive shoes go on sale. You showed me that you weren’t just a doctor; you were also a person.

To the pharmacist who said little, but brimmed with wisdom when he did speak: I wish you were still alive. I think of you often: sometimes when I’m flummoxed over someone’s medication regimen, more often when I’m not sure how to best connect with the person in my care. You are the only person who has ever compared me to a bottle gourd: “Circumstances and people might try to bring and keep you down, but you’re like a bottle gourd in water: You pop right back up again.” After you died, I bought a bottle gourd to remind me of your high praise.

To the male psychiatrist who paid too much attention to me: Everything about that situation still makes me sad, but it helped me grow as a person and as a professional. I now tell trainees—particularly the women—that they must speak up, that they aren’t alone, that they don’t have to put up with bad behavior.

To the psychiatrist who worked as a commissioner for mental health: I wish you were still alive, too. I also think of you often: When systems don’t work and seem designed to fail, when people focus more on how things look than on how they actually are, when money seems to matter more than people…. I wish I could ask you what I should do. You often advised me to continue to ask questions, especially when I wanted to “do” something. I still heed your advice: If it scares you, then you should probably do it. Sometimes it is scary to ask questions, too.

To a male VA attending psychiatrist: Thanks for your candor while I was crying. “I had no idea that you were that upset,” you said. “You should know that you don’t show how you’re feeling. People probably have no idea.” You weren’t the first (nor last) person to recognize that I often don’t show how I’m feeling, but you were the first supervisor to tell me this to my face. You weren’t warm in that moment, but you were kind. And thanks for not freaking out when I started crying.

To my first boss: Thanks for saying explicitly that it’s okay to be mad. As an unintended corollary to the feedback I got from the male VA attending psychiatrist, you told me that it’s okay for people to know that I’m angry. “It shows people that you care. And sometimes people need to know that.”

To all the people who have allowed me to be your doctor: Thank you for your patience. The longer I practice, the more I realize how little I know. Thank you for your grace when I ask you intrusive questions. Thank you for your calling me out when I mess up. Thank you for giving me the opportunity to try to help you. Thank you for thanking me when you are better and don’t need to see me anymore. Thank you for teaching me new things and reminding me of things I still need to work on.

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Consult-Liaison Education Medicine Systems

The Social History.

From the notes I read, it seems that other medical specialties limit “social history” to whether or not someone uses tobacco, drinks alcohol, or uses drugs.

“Social history” is meant to get a sense of the context in which people live. Where do they live? Who do they live with? How did they come to live there? Where did they grow up? What sort of work do they do? How much school have they finished? What do they do for fun? What are the important relationships in their lives? etc.

I almost always start my clinical interviews with the social history. There are several reasons why I do this:

One, it’s a more neutral place to start. My hope is that it will help the person feel more comfortable talking to me. Most of these questions are easy to answer, since many of them overlap with social conversation: Where do you live? How long have you lived there? This is also an opportunity to communicate through non-verbal communication: The nodding, the eye contact, and all the other behaviors that show that I’m paying attention and worthy of trust. (“See, it’s not so bad to talk with a psychiatrist.”)

Two, it puts the information the person shares with me into context. If people don’t have a stable place to live, then they have good reason to feel anxious about their safety and exhausted from poor sleep. If someone lives with other people who are struggling with substance use or are often fighting, then this person may not be able to recruit them to help with the tasks of daily life. They may not even feel safe staying with them, but don’t have other choices. One can’t expect someone to take medication on a regular basis when they don’t have enough money to buy food.

Three, if people don’t want to talk to me for whatever reason, the way they stop the conversation is useful information. Sometimes people are paranoid for a variety of reasons—some based in reality, some not—and they shut down the interview. Sometimes people want to talk to me, but they’re exhausted and ask me to come back later. Sometimes people don’t like something about me: my hair (it’s noteworthy how some people respond to my hair), my ethnicity, my clothes, my sex, the way I talk. I can’t change most of those things, and how people respond to all that tells me (1) how I can better interact with them in the future and (2) what might be going on that is causing them to respond this way. And sometimes people don’t want to talk to me because I’m not conducting the interview in a skillful way: Maybe I’m coming across as cranky, uncaring, or judgy.

Four, and most importantly, I want the person to know that I view them as a human being. I wince whenever someone immediately launches into their mental health history: “Okay, I have a diagnosis of schizophrenia and I take Zyprexa and Cogentin….” This tells me that this person got the message over time that no one is interested in him as a person; people only want to know his diagnosis and medications. But people aren’t their diagnoses or their medication regimens. All people have hopes and dreams; they have things they want to do and people they want to be. While a summary statement might make the interview more efficient, it matters whether this person volunteers at the animal shelter every week because he loves dogs or whether he stays at home and watches TV all day. This information is valuable, regardless of his diagnosis.

It takes time to get a social history. Short appointments, though, are short-sighted. It’s much faster to generate diagnoses from labs and studies; it’s much faster to write prescriptions than to listen to patients. If physicians don’t get an accurate history, then physicians are more likely to generate wrong diagnoses. Wrong diagnoses, along with no information about the contexts in which people live, lead to wrong interventions. Did anyone then actually save any time?

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Consult-Liaison Education Medicine

Thoughts about the Digital Pill.

Reader and stellar nurse Natalie[1. I know Natalie is a “stellar” nurse because we used to work together.] wondered about my thoughts about the digital pill.

My initial reactions were similar to several of those who were interviewed for the article. The digital pill, which provides electronic information to confirm whether someone has ingested the medication, has great potential to become a tool of coercion. Aripiprazole (Abilify) is classified as an antipsychotic medication, which is often prescribed to people who have beliefs that machines and other surveillance tools are in their bodies. Why would the nascent technology of a digital pill make its debut for this population?

I have several other concerns about this digital pill:

(1) The purported mechanism of action for aripiprazole (Abilify) involves hand-waving, which is yet another reason why its debut as a digital pill is perplexing. To the manufacturer’s credit, the package insert for arpiprazole is blunt: “The mechanism of action of aripiprazole in schizophrenia or bipolar mania, is unknown.” (Section 12.1.) The explanation in the scientific papers, though, gets those hands waving all over the place (warning: technical language fast approaching):

The development of D2 partial agonists is a logical strategy for the treatment of schizophrenia because the pathophysiologic mechanism of schizophrenia is thought to be based on too much dopamine activity in some regions of the brain and too little dopamine activity in other regions. A D2 partial agonist can act as a functional antagonist in areas of high levels of dopamine, such as the mesolimbic pathway, but not in areas of normal dopamine levels, such as the nigrostriatal and tuberoinfundibular pathways. Thus, a D2 partial agonist is expected to reduce the positive symptoms of schizophrenia without producing movement disorders or elevated prolactin levels. In regions of low dopamine concentration, such as the mesocortical pathway, a D2 partial agonist will show functional agonist activity.

Put into plain language, what all that means is aripiprazole might stimulate specific receptors in one part of the brain, but block those same receptors in other parts of the brain. The concentration of dopamine might determine whether aripiprazole stimulates or blocks those receptors.

I’m skeptical.

That’s like an antibiotic that only kills one specific type of bacteria in one part of the body, but doesn’t kill that same specific bacteria in other parts of the body.

How does that work? Especially since science has yet to determine the underlying causes of psychotic disorders, such as schizophrenia?

So, in sum, this is a digital form of a medication that has an uncertain mechanism of action for a disease that we don’t fully understand.

What?

(2) The focus on adherence to medication assumes that the ingestion of medications is the most important aspect of treatment. This may be true for some individuals, but does not apply to everyone. Psychiatry focuses on maximizing function and quality of life. Sometimes people can attain both without taking digital pills daily.

(3) Most people under my care don’t have access to technology like smart phones. Some of these individuals also have the most severe symptoms and are the most likely to benefit from a variety of interventions: Skills coaching, housing, nutrition, exercise, art, and talk and behavioral therapies, in addition to medication.

(4) I don’t know how the data from this digital pill will actually change care. Psychiatry, for now, still relies on the observation of thoughts, emotions, and behaviors of people. Whether someone is taking their medications or not may not actually change treatment plans.

For example, say Natalie is under my care and takes a digital pill. I learn that Natalie takes this medication five days out of seven. All sources report that she’s doing okay: She’s getting along with her family, is going to school or work, is keeping up with her rent, and continues to follow the blogs she likes. Do I encourage her to take the medication every day? What more gains might she make? What if it detracts from her quality of life to have to take a medication every day, particularly when she’s doing okay?

Or, what if the digital pill tells me that Natalie hasn’t taken medications at all since I prescribed them to her? And Natalie continues to experience significant symptoms? I guess it’s helpful to have confirmation that Natalie isn’t taking medication, but, if I have sufficient rapport with Natalie, she’ll straight up tell me that she’s not taking it. Why use a digital pill when I can get the information from someone directly? Particularly when she can tell me the specific reasons why she doesn’t want to take it?

Or, what if the digital pill tells me that Natalie is taking the medication everyday, but she also continues to demonstrate significant symptoms? Again, the confirmation that she’s taking her medications could be helpful, but if I have rapport with her and she continues to suffer from symptoms, it’s likely that she would tell me this information, anyway.

If physicians want people to trust them, then physicians must show that they trust the people under their care. There are easier and more compassionate ways to get accurate information without resorting to a digital pill.

(5) Lastly, who are we actually treating with this digital pill? Who is going to feel better with the data the pill generates?

This data won’t tell individuals anything they don’t already know. They will know if they took their medications or not. (And savvy patients will figure out a way to subvert this digital pill reporting: Maybe they will give the meds to a pet or to another person.) This data is meant to help physicians feel better, not patients.

If the goals of psychiatry are to help reduce suffering, improve function, and help people live the lives they want to lead, we cannot rely on medications alone to achieve this, particularly for those individuals with significant symptoms. Even if the data shows that someone is taking medications daily, that process measure is meaningless if the person’s overall function and quality of life remains poor.

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Education Homelessness Medicine Nonfiction Policy Systems

People Get Better.

“What?!” he exclaimed. “Are you serious?”

“Yeah,” I replied, puzzled.

“That’s… amazing.”

“Yeah, it is.” I paused, finally realizing that he had never heard me talk about this before. “It actually happens a lot. People get better. People get better all the time.”

When I first met him, he screamed at me, his face red, spittle flying from his lips. He refused to believe I was a physician.

“Women can’t be doctors! They can’t!”

He did believe, though, that televisions could control his thoughts.

“They know what I think! When they start talking, they control what I think and what I say and what I do!”

He drew a swastika that covered the entire wall of his jail cell.

“Yes, I believe in white supremacy! But I’m not part of a group!”

He accepted medications on his own. First, the yelling stopped. Then, the swastika disappeared. Drawings of cute farm animals took its place. Within a few weeks, he greeted me with a smile.

“Hi, Dr. Yang. How are you doing today? I hope you’re well.”

He invited me to sit at the small table next to the kitchenette in his apartment.

“You want anything to drink?”

“No, thank you. How are you doing?”

“I’m okay. What do you know about the Mediterranean diet? I want to try that. I want to lose some of this weight.”

After discussing the merits of vegetables and lean proteins as they related to heart health, he leaned back in his chair. He then blurted, “It’s been six months since I smoked a cigarette.”

He never smiled when he shared his accomplishments. His condition prevented him from doing so. I smiled for him.

He resumed musing about dietary changes. I mused about how far he had come: Just 18 months ago he was living on the streets, often snarling at strangers and the voices that only he heard. He came to the attention of the police when he chased a young mother pushing her baby in a stroller. He threatened to beat them with the metal pipe in his hand. The police thankfully sent him to the hospital for care.

“Thanks for seeing me,” he said as he walked me to the door. The voices hadn’t completed disappeared, but he could ignore them now. “I like steak and potatoes, but I’ll try the leafy vegetables.”

He used both hands to smear his own feces on his arms, chest, and belly. He applied toothpaste to his elbows and his knees. I asked him why.

“because it’s protection it’s protection against all of you I shouldn’t be here I’m fine I’m not sick you don’t understand who I am they all know who I am you would be scared too if you knew who I am people know me from way back—”

He began howling at the door.

Within days of him receiving medications, all of that stopped. His jail cell was clean. He took showers. He never spoke of what happened. Neither did I.

I was taking a walk a few months later when I heard someone call, “Hey, Dr. Yang!”

I turned around and saw a group of men in uniform working. This man, suited up like his colleagues, waved at me and smiled.

I couldn’t help but smile—this is fanstastic!—but felt a twinge of embarrassment. Did he know that he had called me “doctor”? What would his coworkers think?

First do no harm. I waved back.

“Nice to see you, Doc,” he continued. “I’m doing good.”

“I’m glad to hear that. Take care of yourself.”

“I will, Doc. Thanks.”

People get better. The science hasn’t yet generated interventions that guarantee that everyone will get better. Furthermore, some people who could get better can’t access care due to barriers related to finances, policy, and other systemic factors.

Until then, we must share both stories and data (try this, this, and this) that people get better. It is amazing, but it shouldn’t be surprising.

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Education Nonfiction Reflection

Primary and Secondary Emotions.

I used my left arm to stop the tears from rolling off my cheeks and onto the lotus root. Had I known that Act One of episode 597 of This American Life would make me cry to the point that I would have to wipe the snot from my nose multiple times with my arm, I wouldn’t have listened to it while making a lotus root salad for a party.

People warned me that my grief about my mother’s death would continue to fluctuate with time. It had been many months since I last cried; how was I to know that learning about the wind telephone in Japan would induce such a reaction?

Perhaps my grief wasn’t my own. My father’s older brother recently died.

“I’m glad I could help with the funeral arrangements for him,” my father murmured to me. “I went through all that just three years ago, so I knew what to do.”

I nodded. He sighed.

“He was my older brother. It was still a shock.”

I looked away. He didn’t need to see his daughter trying to hide the sadness from her face.

I first learned about “primary” and “secondary” emotions while learning dialectical behavior therapy. Marsha Linehan points out that there is

a distinction between primary or “authentic” emotions and secondary or “learned” emotions. The latter are reactions to primary cognitive appraisals and emotional responses; they are the end products of chains of feelings and thoughts. Dysfunctional and maladaptive emotions, according to Greenberg and Safran, are usually secondary emotions that block the experience and expression of primary emotions.

Some (corny) examples are helpful here:

Primary emotion: “All right! I did well on that test! I feel happy about my performance!”
Secondary emotion: “But wait! I still missed some items on the test. I feel ashamed that I felt so happy about how I did. It’s not like I got a perfect score.”

Primary emotion: “I can’t believe she did that! Who does things like that, anyway? I feel angry.”
Secondary emotion: “Maybe I’m overreacting about her. I don’t want people to think I’m a b!tch. I’m disappointed that I can’t control my moods better.”

Not much time has to pass between the primary and secondary emotions. In fact, sometimes people experience only the secondary emotion. The experience of the primary emotion gets lost, even though the primary emotion reveals useful information about the situation and how the person relates to it.

Infants and children experience and express primary emotions. We become acquainted with secondary emotions as we age.

Primary emotion: I feel sad about the death of my mother. I witnessed how her death affected my father, who lost his companion of forty years. There are things that only my father and I understand; we can’t talk about those things with anyone else because they just won’t get it. I feel sad that he is at that age where multiple loved ones are dying because their time has run out. I feel sad when I consider the loneliness he must feel at least some of the time.

Secondary emotion: God willing my father dies before I do: No father should outlive both his spouse and child. Of course I will feel grief when he dies. Will it be worse than the grief I felt when my mother died? What if it’s too much grief? What if I don’t have the mettle to tolerate it?

What will I do when my only option is to use a wind telephone?