Category: Education

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Education Medicine Policy Systems

Inspiration from the Surgeon General.

Somehow people knew he was about to enter the room. The thirty or so people in the room were seated, though people began to stand up.

“Are we supposed to stand up for the Surgeon General?” I asked the person sitting next to me.

She shrugged. If we remained seated, everyone would have noticed. So we stood up.

“I’ve been in this position for a year and a half,” Dr. Murthy said, “and I’m still not used to people standing up for me. Please sit down.”[1. I learned later that the Surgeon General has the rank of a Vice Admiral, as the role oversees uniformed health officers. That’s why people stand up for the Surgeon General.]

We were all in that room for about an hour, but Dr. Murthy said little. After some opening remarks about the Turn the Tide initiative related to the opioid epidemic, he asked the audience to tell him what was going well and what could use improvement.

I had never met him before, but I was immediately struck with his listening skills. It was as if he was taking a history from a multi-person patient. He made and held eye contact. He didn’t fidget. He spoke in a quiet yet firm voice. Though he didn’t come across as warm, it was clear that he was interested in and paying attention to whoever was talking to him. His thoughtful follow-up questions indicated that he was listening to what people were saying to him.

He seemed like a good doctor.

As I had never met a federal official before, I later learned that Dr. Murthy was also unusual in that he took notes. (Fun fact: He’s left handed.)

“These are usually publicity events without a lot of substance,” a more seasoned co-worker commented.

By the time the meeting was over, he had covered a sheet from a yellow notepad with copious notes. He expressed what seemed like genuine thanks to us for our time and perspectives.

It was through luck only that I was there. A colleague told me a few days prior that the Surgeon General was scheduled to speak to a local task force related to the opioid epidemic.

“The Surgeon General?” I blurted. “I’d love to hear what he has to say.”

“Then you should come.”

“What?”

Afterwards, as the Surgeon General’s staff were trying to hustle him out the door, the same colleague who invited me to this event gave me A Look. Only I could see the thought bubble above his head: “Go ask him for a photo!”

Though I appreciated Dr. Murthy’s humility, thoughtfulness, and professionalism, I was also grateful and amused with his willingness to stop for a photo.

Earlier that day I was seeing patients.

“Do you know how much longer you’re going to be jail?” I asked.

“Ten or eleven days.” He looked at my left hand. “You’re married?”

“Yes.”

“I should start going to NA meetings again. I’m never gonna meet a woman in here and I get so depressed about not having a family. I want a wife and kids, like my brother. I don’t know why he got so lucky and I got screwed. The TV doesn’t talk to him, he’s got a wife and three kids, God blesses him, but I will wait because the meek shall inherit the earth—”

“What do you think will help you not pick up when you get out?”

He shrugged. “I still don’t have a place to live. Dope helps me feel better.”

We looked at each other and said nothing.

The reality is that the Surgeon General (or any other public official) is just one person. Though he has a grand title, he alone cannot make improve health care. He is part of a system. We can only hope that he and his office will be able to shift the system—even if only just a bit—so that it works better to serve the US population.

What the Surgeon General can do and, at least for me, has done, is inspire physicians to get involved and do better. He could have swept into the meeting and spoke at length about his accomplishments and his status within the federal government. He instead presented himself as a humble ambassador and servant. He demonstrated interest in what our locality has witnessed and experienced. He recognized that, even though he was an academic physician, he is now too far removed from clinical care to speak first as an expert. He solicited and accepted feedback, some of which was discouraging. He was professional. He wasn’t defensive. He acknowledged that it may seem like our feedback would disappear into a void in Washington, DC, though everything else he was actually doing during the meeting gave us hope otherwise. It’s quiet leadership.

There are a lot of problems with health care. Physicians and patients both know this. Physicians are trained to take care of people, not to create and manage financial systems that should only support the relationships between physicians and people. However, if physicians are not involved in the conversations about these systems, then we are not advocating for the patients we serve and the profession that gives us the privilege of doing so. Yes, I know we’re too busy taking care of patients to participate in these conversations that can seem bloated and irrelevant. However, if we don’t get involved to define the problems and solutions, how could we ever expect these systems to improve?

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Consult-Liaison Education Lessons Nonfiction Reflection

Five Things You Can Do When You Have to Talk to Someone You Don’t Like.

We all have to talk to people we don’t like, whether in our professional or personal lives. We try to avoid these people. We try to work around them. Sometimes we spend a lot of energy trying to get away from them. And, despite our efforts, we often still have to spend time with them.

Most people don’t like the experience of disliking people. Some blame it all on the disliked person. Some people assume all the blame themselves (“why don’t I like that person? what is wrong with me?”). And, despite self-reflection (or lack thereof), the uncomfortable sensations remain.

It’s okay to dislike people. It happens. Sometimes we don’t have rational reasons for disliking people. Even if the reasons elude us, one of the most useful things we can do for ourselves (and for everyone else) is to acknowledge our dislike. Once we recognize our internal reality, we can then take useful steps in our external reality when we have to spend time with these people.

Here are five things you can do to make the best of the time you have to spend with someone you don’t like:

1. If they are much older than you, really look at them and picture them as kids. Kids are cute. All of us were kids at one point. Sometimes things happen to kids that lead them to act in certain ways as adults. These certain ways helped them cope with and survive in the world. Maybe these strategies don’t actually work well now, but they may have been lifesaving when they were kids.

Have compassion on the kid.

2. If they are much younger than you, really look at them and picture them as elderly people. You might recognize that, if they keep doing whatever it is that they are doing, they will have difficult lives as older adults. Maybe they haven’t learned what they need to learn yet. Maybe the time you spend with them can help them learn something different so they aren’t destined for decades of misery.

Have compassion on the elder.

3. Try to get to know them better. Abraham Lincoln remarked, “I don’t like that man. I must get to know him better.”

Yes, this means that you might have to spend even more time with someone you don’t like. When you start exercising curiosity about people you don’t like, though, you often learn that you both have something in common. Sometimes you learn things about the person’s past that might explain why they he does the things he does. Instead of thinking of him as an “annoying dickwad”, you may notice that you now think of him as “that poor guy who no one cared for as a kid”.

4. Assume that the person is having a rough time in his life. None of us shine when we’re dealing with the problems and failures that inevitably occur. We often have no idea what challenges people have in their lives. Even though their challenges may occur in contexts that have nothing to do with you, the ways they deal with those challenges may affect how they interact with you. What they do that vexes you may be the best way they know how to cope.

5. Approach them with the assumption that these people are your teachers. Everyone you meet can teach you something. Because we often have no idea what has happened or is happening to people, it is foolish to believe that we know more about life than those around us. This person might teach you how to show more compassion or exercise more patience. This person might be an accurate reflection of those aspects of you everyone else finds annoying. Your reaction to this person could help show you how you can make your other relationships better.

You may protest that these suggestions may not reflect actual reality: “These are just mind tricks you play on yourself!” However, you cannot control the behavior of other people. You are limited to choosing how you can react to and interact with the people you dislike.

Thus, if the goal is to make the best of your time with people you don’t like, would you rather be “right”? or would you rather be “effective”? These five suggestions may not be “right”, but they are more likely to make you effective.

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Education Nonfiction Policy Reflection Systems

A Review of the National Council for Behavioral Health Conference.

Those of you who follow me on Twitter already know that I spent much of last week in Las Vegas. I attended the National Council for Behavioral Health Conference, “featuring the best in leadership, organizational development, and excellence in mental health and addictions practice.” Here are my reflections about the experience:

It was large. I have never attended a conference with 5000 other people. I already find Las Vegas overstimulating. Not being able to get away from thousands of people for hours on end was draining for me.

There were many sessions I wanted to attend, but could not. This, of course, was a function of the size of the conference. Humans, thus far, can only physically be in one place and mentally elsewhere. During this conference I often wished I could physically be in two places at once.

The sessions that most inspired me often had little to do with formal behavioral health. Nora Volkow, the director for the National Institute of Drug Abuse, gave a talk about the neurobiology of addictive behaviors. Did I learn anything new? No, only because I had learned this while in medical training. Did she present the information in an engaging and compelling way? Yes.

Charles Blow, an opinion writer for the New York Times, authored a memoir about his youth and past sexual abuse. During his talk he read from his book and shared his reflections about his experience. Did I learn anything new? Nothing obvious that would affect either my clinical practice or policy considerations. He won me over with his personal perspective, grace, and vulnerability.

Susan Cain spoke about introversion and leadership. Did I learn anything new? No, because I had already read her book. Was it nonetheless worthwhile to hear her speak in person? For me, yes.

The conference featured a large session called “Uncomfortable Conversations”. The intention was for Big Names in the field to discuss controversial topics. These included involuntary commitment, confidentiality laws that are specific to substance use disorder treatment that can interfere with clinical care, and the concept of cultural competency. Each pair, however, had less than ten minutes to discuss their issue. The moderator also seemed to speak more than each member of the pair. The session could have been thoughtful, though ended up feeling underdeveloped and unfocused.

Where were my psychiatrist colleagues? I understand that this is my own issue—after all, this was not a physician conference. The National Council, however, is supposed to be the leadership conference for community behavioral health. Are psychiatrists involved in leadership in community behavioral health? If not, why not? [1. As I have noted elsewhere: “Physicians, as a population, don’t advocate for ourselves as much as we should because we’re “too busy taking care of patients”. This is true. However, our busy-ness creates a vacuum where non-physicians step in and make decisions for us. We then express resentment that we have to follow the edicts of people who have never done the work. If we did a better job of regulating and advocating for ourselves, we might not be in this position.” Advocacy in this case is leadership.]

Only two “small” sessions I attended featured physician presentations. One involved the introduction of trauma-informed care into primary care settings. The other discussed a concrete integration of mental health, substance use, and primary care services. In both cases the physicians were family practice physicians. Which, to be clear, is fantastic. We must work across systems to provide good care for individuals and populations. I nonetheless felt both puzzled and disappointed with the lack of psychiatrist representation. [2. To be fair, Nora Volkow and several of the panelists for the “Uncomfortable Conversations” are trained as psychiatrists.]

There was a “medical track” meant for medical professionals. Few of those sessions discussed systems issues or leadership. I had planned to attend one that discussed guidelines for benzodiazepine use, though there was no room by the time I arrived. (One of my colleagues, a psychiatrist, later told me that many attendees were not doctors.)

The conference will be in Seattle next year. My colleagues and I are already discussing what we can present.

A lot of people want to do good. I often comment, “Life is terrible… and life is wonderful.” That people have done good work to help others and want to share what they learned in the process is remarkable. That people continue to strive to provide useful services to people who are suffering is humbling. That people are creating new programs to help solve problems, often rooted in inequality, a variety of disparities, and the randomness of existence, is inspiring.

When we have our heads down in our own work, we often forget that we are part of a system. Though I have critical opinions about the conference, I am grateful that I could attend. May we all seek inspiration and always learn from others.

Categories
Consult-Liaison Education Lessons Observations

More About Questions.

Last week I riffed on the importance of “what is the question“. This week I will riff on a related topic: “How will the answer affect what you do next?”

If the answer to your question won’t change what you will do, then perhaps you don’t need to ask the question.[1. This I definitely learned in medical school. It was usually phrased, “How will this affect your management?” If you’ve made the decision to prescribe an antibiotic for pneumonia, then there’s no reason to get a chest X-ray. It doesn’t matter what the answer is to the question, “What will we see on the chest X-ray?” Thus, don’t order the X-ray.]

If you know that you friend isn’t the biggest fan of cake, but you’re going to serve cake at the party anyway, there’s no point in asking your friend, “Do you like cake?” or “Do you mind if I serve cake?”

Sometimes we ask questions not because we want to learn the answer, but because we want to say something. In the above example the question “Do you mind if I serve cake?” may actually mean “I hope you won’t feel angry or disappointed that I am serving cake”.

Consider meetings or conferences where audience members have opportunities to ask the speaker questions. Sometimes the people who raise their hands to ask questions either (1) never ask an actual question, or (2) ask a question that they then answer themselves, whether the group wants to hear it or not.

To be clear, I’m not saying that we should never ask questions unless the answer will influence our next actions. Asking questions is how we learn about ourselves and the world around us.

When I first moved to New York from Seattle, many of my colleagues in New York asked me about how much it rains in Seattle.

“It actually rains more in New York than it does in Seattle,” I would reply, sometimes with unnecessary smugness.[2. I do like the Merriam-Webster definition of smug. It makes it clear that it is always annoying and never necessary to be smug.]

The question was, “Does it rain more in Seattle than it does in New York?” The answer was “no”, but it didn’t change anything anyone did. No one moved from New York to Seattle to experience less annual precipitation. It didn’t stop me from moving to New York. I still wore trench coats in both cities (though got one with more style in New York) and covered my head as needed. That there is more annual precipitation in New York is just interesting.

It is nonetheless worthwhile to consider the reasons behind questions you ask. Sometimes the answers to your questions will affect what you do next. Sometimes your questions help you learn more about other people or phenomena in the world. Sometimes your questions address only your own psychological needs, which often has bad outcomes for everyone involved in the conversation (e.g., “Do I look fat in this?” or “Are you getting your period?”).

Be careful what you ask for.

Categories
Consult-Liaison Education Informal-curriculum Lessons Medicine Reflection

What is the Question?

I can think of only two times in my life where I received formal instruction on how to ask questions.[1. Without a doubt there have been more than two occasions when someone taught me how to ask questions, but it appears that I either was not paying attention or the lesson was not memorable.]

The first instance was when my parents taught me how to order food in a restaurant. They told me to make a single choice and have my order ready before the wait staff appeared. (“Don’t waste their time.”) They told me to phrase my order in the form of a question:

RIGHT: “Can I have the grilled cheese sandwich, please?”

WRONG: “I want the grilled cheese sandwich.”

My parents also told me to look at the faces of the wait staff and to speak loud enough so they could hear me. They also told me to thank them after they took my order.

(When I became more finicky about sentence construction, I changed the beginning of my orders to “May I…?”. This is mostly due to my 6th grade English teacher who, in his booming voice, would challenge any student who said, “Can I…?” “I don’t know, CAN you? CAN you go to the bathroom? If you CANNOT, perhaps you should see a DOCTOR. MAY you go to the bathroom? Yes, you MAY.”)

In sum, I was supposed to know what I wanted and exercise good manners.

The second time I received formal instruction on how to ask questions was during my third year of medical school.[2. Of course I received formal instruction on how to ask questions throughout my training as a medical student and as a psychiatry resident. However, that was over the course of years and done with varying quality. There were also all the people who taught me how to ask questions and I didn’t understand at the time that they were teaching me how to do that. Communication is difficult. This also explains why my efforts to ask boys out on dates in my youth often resulted in said boys looking at me askance and running away.] Interns and residents often asked medical students (e.g., me) to call consults.

Here’s the thing: When you’re a medical student, you don’t know how to do things like call consults because you don’t entirely know what you’re doing. Mastery comes with practice. Mastery also results from direct feedback, which often comes from exasperated and impatient residents.

When you call a consult you’re asking another service to help you with your patient. For example, if I’m a surgeon and I have a patient who stabbed himself multiple times in the abdomen in an attempt to kill himself, I’ll do the surgery to look around inside and make sure there aren’t injuries to internal organs. However, as a surgeon, I don’t know what to do about my patient’s urges to stab himself, so I’m going to call the psychiatrist to ask her for help.

WHAT IS THE QUESTION?

A surgical intern named Tom[3. Tom had cropped blonde hair. He wore leather pants sometimes. He often went dancing when he wasn’t working. He was smart and, perhaps more importantly, he was kind.] taught me how to call a consult while we were speeding around the hospital one day.

“Before you call a consult, you have to know what you want. What is the question you want answered? The patient is your patient, so you have to provide most of the care. But if you need help, what do you need help with? Don’t just say that the patient has diabetes and high blood pressure. That’s not a question and it’s not clear what you want. Make your question very clear:

‘My patient has diabetes and high blood pressure. He took insulin regularly before he came to the hospital, but now his blood sugars are high. They haven’t been below 300 since he’s been here. Can you help us bring his blood sugars back down?’

See how that’s a clear question? If you ask a clear question, you’ll get answers that will actually help you.

And be nice. Some of the residents you talk to won’t be nice, but that’s just because they’re tired and stressed out. Don’t take it personally.”

In sum, I was supposed to know what I wanted and exercise good manners.

To be clear, it’s not like I had this one conversation with Tom and I thereafter called in stellar consults. I still went on for too long and didn’t share pertinent pieces of information. Residents interrupted me before I had spoken for five seconds and they often made no effort to mask their annoyance.

But! It set me on the path of continually clarifying for myself what I wanted and how to craft better questions. Focusing on “WHAT IS THE QUESTION” has helped me as a psychiatrist (much of the work is often helping other people clarify for themselves what they want), a teacher (if people don’t understand something and get stuck, it’s often because they don’t know what they want to know), and as a human being (when meeting someone new, the question might be as simple as, “How can I make this person feel comfortable so maybe we can become friends?”).

Sometimes asking questions is more complicated than just knowing what you want and exercising good manners (e.g., “Will you marry me?”). Doing both, though, is an excellent place to start.