Category: Informal-curriculum

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Informal-curriculum Medicine Reading Systems

Recent Readings.

Stack of read newspapers.
Photo by brotiN biswaS

On medicine being agents of social control. These three news articles highlight the misuse of authority within the context of medicine:

Delta ‘weaponized’ mental health rules against a pilot. She fought back. In short, a woman named Karlene Petitt was (and remains) a pilot for Delta airlines. In response to a general exhortation from Delta leadership to speak up about safety issues, she submitted reports that did just that. In return, Delta leadership sought to silence her and initiated a process to deem her “too mentally unstable” to be a pilot. Delta recruited a psychiatrist who provided a diagnosis to support this argument. (The psychiatrist apparently diagnosed her with bipolar disorder because of her many accomplishments—“well beyond what any woman [he’s] ever met could do”.) She contested this and took legal action. She won.

How a Chinese Doctor Who Warned of Covid-19 Spent His Final Days. This 16-minute video investigation includes remarks from a physician who provided care to Dr. Li Wenliang, the ophthalmologist in China who tried to alert the public about Covid-19 before he died from the infection himself. Around minute 11 of the video, both the narrator and the physician comment that hospital administrators wanted the health care team to provide an intervention (ECMO) that was not clinically indicated. However, it would buy the hospital administrators time and allow the hospital to report that the health care team “did everything”. The physician states that using ECMO would have been both a violation of medical care and medical ethics. This is an example of “reputation management” superseding clinical judgment.

Woman’s legal quest illuminates the rights of hospital patients who want to leave. Here, a woman voluntarily agreed to enter a psychiatric hospital for care, but was not permitted to leave upon request. Available documentation suggests that she was not at risk of harming herself or others at the time of her request to leave. Under these circumstances, that means the hospital was essentially holding her captive. (This is reminiscent of “On Being Sane in Insane Places“, where context affects how we evaluate situations.) Even worse:

“All patients admitted to the facility,” the manager said, meet the criteria to be involuntarily committed, “even voluntarily admitted patients.”

The manager told DOH investigators that staff “do not orally notify voluntary patients” of their right to be released immediately, despite a state law requiring this disclosure. If they did, he said, “Everybody would be asking to leave.”

Those two short paragraphs reflect poorly on the hospital in question.

On the death penalty. The first two articles present opposing perspectives on the death penalty. The third article provides a first-person account of being in prison, which adds context to the first two articles.

If Not the Parkland Shooter, Who Is the Death Penalty For? Here, the author describes justifications for punishment:

Society embraces four major justifications for punishment: deterrence, rehabilitation, incapacitation and retribution.

I’ve not seen it described this way and appreciate the framework. This might be a red herring: The author also argues that the Parkland shooter’s “human dignity requires his just punishment [with the death penalty] as an end in itself”. I struggled to wrap my head around this one: We usually cite people’s humanity and dignity as reasons to keep them alive, not to kill them.

I Wish the Jury Had Not Sentenced My Family’s Killer to Death. In contrast, the author here argues how the death penalty, while maybe just, doesn’t actually solve any problems. It instead only prolongs suffering for the families of victims. Also, “death by incarceration” is still death. (I also appreciated her firm recommendations about how to support people who experience unspeakable tragedies.) While the author of the previous pro-death penalty piece focuses more on theory and logic, the author here focuses more on practicalities and emotions. Both models have value. Both articles made me consider my own stance on the death penalty.

Prisoners Like Me Are Being Held Hostage to Price Hikes. The author of this piece is currently in prison. Though I have never worked in prison, I have worked in jail. His descriptions about commissaries, food items, and access to various items seem similar to what I have observed in jail settings. (It also continues to baffle me how businesses are allowed to make money off of people in jail—including medical care!!!) Nobody is spared from inflation and price hikes.

To end this on a lighter note: This artwork from Andy J. Pizza made me feel a variety of invisible things:

Categories
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.

Categories
Consult-Liaison Informal-curriculum Lessons Medicine

You Don’t Have to Like Everyone.

You don’t have to like everyone under your care. And you probably won’t, which is okay.

Own how you feel. If you insist on telling yourself that you should like someone when, in fact, you don’t, it will come out in other ways: The tone of your voice, the expressions on your face, the way you position your body.

There might completely understandable reasons why you don’t like the person under your care. Maybe he never seems to hear what you say. Maybe he doesn’t follow any of your recommendations, but he blames you for lack of healing. Maybe he expresses opinions you find offensive. Maybe he calls you racial slurs. Maybe he’s thrown things at you. Maybe he threatens to rape you. Maybe he’s told you that he will kill you and your family.

People do things like that for reasons that make complete sense to them. You may disagree with or misunderstand their reasons, but despite that, they are still people. Even though you may dislike some people under your care, you must still recognize that they are still human beings. The moment you refuse to recognize the humanity of the other person, you are at risk of inflicting violence upon them. Violence can manifest in many ways, including neglect.

First, do no harm.

It is possible to dislike someone and do no harm.

When we don’t like someone, it is much easier to assign blame entirely to the other person (e.g., “He’s an annoying @$$hole”). While it is possible that the problem has nothing to do with you and everything to do with the other person, that doesn’t change the fact that you cannot control other people. You can’t make someone less of an @$$hole. You, however, can make yourself view the situation in a different perspective.

Own how you feel. Let’s say he is, in fact, an @$$hole—something you cannot change. What if you focused instead on yourself?

“I really don’t like him. I feel dread whenever I have to see him.”

The reasons behind your dread make complete sense to you. When you acknowledge your dread and dislike to yourself, you give yourself more options as to how to proceed. You now have more control over the situation.

When you don’t like someone who is under your care and you acknowledge this, you can:

  • get support from your trusted colleagues. You can tell them how much you don’t want to see this person, how anxious and annoyed you feel about having to do this, and how much you don’t like this person. Get it out of your system ahead of time so you can be the professional you want to be when you actually see this person.
  • activate your internal coach. You can take some deep breaths and say a silent prayer before the interaction begins. You can rehearse some evacuation plans in case things start to run off the rails. Your internal coach can recruit your internal cheerleaders afterwards if the conversation goes well.
  • pause and remind yourself of your purpose. Your job does not include judging or shaming the person under your care. Your job isn’t to like the person under your care. Your job is to help the individual improve his health. Sometimes the people you care for have terrible life circumstances that contribute to the behaviors that you don’t like.
  • ask a colleague to see the individual so you don’t have to. Sometimes it is clear that the clinical relationship won’t work out at this time. We can’t be effective with 100% of the people we see (though we can try). Sometimes, the best way we can help the people under our care is to remove them from our care. (Sometimes, though, this isn’t an option.)

It’s often helpful to focus on the behaviors of an individual. When you focus on behaviors, you are more likely to remember and respect the person’s humanity. This keeps us professional and kind, even if we aren’t warm and smiling.

Indeed, he may do things that you don’t like… but he may also do things that you do like. And when we offer genuine thanks to people when they do things we like (e.g., “Thanks for your patience while I was asking you all of those personal questions,” “Thanks for summarizing your story quickly for me,” “Thanks for not calling me names today”[1. I have actually said, “Thanks for not calling me names today!” to people under my care and, no joke, the vast majority of them never address me with bigoted phrases ever again.]), people are almost always going to do those things more often.

You don’t have to like everyone under your care. Once you start owning how you feel, though, you might find that, most of the time, you do.

Categories
Informal-curriculum Medicine Nonfiction Seattle

My Seattle Times Op-Ed about #MeToo in Medicine.

The Seattle Times published an op-ed I wrote! Their editorial staff provided the title, #MeToo in medicine: ‘Who would believe a trainee?’

I wonder: What if I had a different byline? Would the Seattle Times have published it if I worked as a nurse? medical student? medical assistant?

What if I worked as a janitor in a hospital? Or in housekeeping?

What if I waited tables? worked in retail? had a job that is “off the books”?

The last sentence in my op-ed is “I was fortunate, but not all women are.” I was fortunate in that I had support from supervisors and colleagues, and that the psychiatrist in question didn’t do anything worse.

I remain fortunate, though, in that I have the privilege to be able to share this story to a wider audience. I have access that other people lack. And those are the people we should consider about when we talk about “#MeToo”.

The senior psychiatry resident at the University of Washington School of Medicine warned me ahead of time. She laughed as she said, “He’s weird. You’ll get used to him.”

When I first met with him, the psychiatrist lazily spun in his chair, his left hand tucked into his pants, his thumb hanging out. After he told me his expectations as my supervisor, he patted my right thigh as he ended the meeting.

I spent one day a week training in his clinic. He often put his hand on my shoulder. If he sat near me, he extended his arm to pat my leg. When I sat far from him, he crowed compliments in front of patients and other staff: “Dr. Yang is one of the best residents who has ever worked with me!”

He began to send emails to me at all hours of the day and night. They stopped referring to clinical research and developments; now he wrote of art, history and music that he thought I would enjoy. Some of the timestamps on his emails were near 2 a.m.

“Do as I say, don’t do as I do,” he chided in his emails. “Good night.”

My discomfort increased over time, though I wondered if I was overreacting. After all, didn’t another resident tell me that he was weird? She didn’t seem distressed with his behavior. Maybe I was too sensitive.

I asked two other supervisors, both psychiatrists, for advice. The male psychiatrist was angry and swift in his response: “You have to tell your residency director. This isn’t right.”

The female psychiatrist wavered. “I don’t know,” she said after a long pause. “It’s up to you if you want to say something. It could turn into a ‘he said, she said’ issue.”

She had a point: Who would believe a trainee over a tenured professor? Would he retaliate? How would this affect the rest of my training?

I decided to talk with him first. My request seemed reasonable: “Could you please stop touching me and stop sending emails to me that are unrelated to clinical work? I feel uncomfortable when those things happen.” I rehearsed.

The next time I saw him, he greeted me with a pat on the shoulder. I felt my face flush as I stammered, “Could you please stop touching me? It makes me feel uncomfortable.”

He paused, then smiled. “Why didn’t you tell me sooner? It’s not that big of a deal. I’m just being friendly.”

It was a big deal: He stopped talking to me entirely when we were in front of patients. He stopped teaching me. At what would become our last meeting together, he refused to acknowledge my concerns about a clinical issue. It seemed like he was trying to pick a fight with me. We fell silent. He looked at me with amusement. I glared at him.

“Are we done?” I still felt like I needed his permission to leave.

“Yup!” He grinned. It was clear I had to talk with my residency director.

She believed me. She was swift and immediately pulled me from the rotation.

One of my fellow trainees, a robust man who played football in college, was assigned to work with him for the following six months.

My fellow colleague believed me. He was swift. He objected and asked for another rotation, stating that he didn’t feel comfortable working with a physician who had mistreated another trainee.

The psychiatrist ultimately left the institution, following an administrative leave.

Sexual harassment occurs in every profession, even medicine. To stop this, we need as many people as possible — men, women, colleagues, advisers and leaders — to support women and act swiftly when these events occur. I was fortunate, but not all women are.

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Informal-curriculum Nonfiction Reflection

Bias.

“I’ve been alive for too long,” he sighed. “I will be 200 years old in two months and four days. I was born in 1817, you know.”

“200 years is a long time,” I replied. While he wasn’t 199 years old, the wrinkles around his eyes, the knobbiness of the knuckles on his hand, and his slumped posture made him look older than his actual age.

“I’m an angel,” he continued. “I do what I can to help people, as that is my mission from God.” His thin frame quivered as he coughed into the crook of his elbow. “God sent me down from heaven 200 years ago. People are drawn to me. Animals are drawn to me. They know that I can help them. I give away my food, I give away my cigarettes, I give away my marijuana. God gives me instructions about how to best help people.”

“Would you miss God’s voice if it went away?”

The Angel bit his thin lip before responding. “Maybe.” He looked worried.

“You seem to appreciate the guidance,” I said, though we both recognized that I was actually asking a question.

“Sometimes God says helpful things,” the Angel answered. “Sometimes… not.”

He shared that sometimes demons speak to him, too. They whisper and shout amidst his thoughts, pointing out how his efforts are useless, that no one cares, that there is no value to his life.

“What has stopped you from killing yourself?”

The question had barely left my lips before he answered, “It’s a sin.”

The cases of beer helped to mute the voices of God and the demons, which often became a cacophony when the light of heaven was gone. No, he didn’t think that the beer was hurting his liver; maybe it was even helping it.

“I didn’t get the hepatitis from drugs,” the Angel offered. “I wasn’t feeling good, I was sick. The doctor tested me and said I had hepatitis. He told me that I had to tell anyone I was having relations with. When I told the lady I was seeing at the time, she said, ‘You got that from me.’ I wish she had told me that sooner. I would’ve used protection if I had known that.”

The Angel didn’t know when he was getting out of jail. We discussed what treatment would best help him. When I asked if he had any questions for me, he shook his head.

“Feel free to come back any time to talk,” he said with the same polite manner he showed for the half hour we spoke. He bowed his head.

You can look up an inmate’s charges on the internet. It’s public information. You won’t learn what specifically happened that resulted in the arrest, but you will learn the alleged reason for why the person is in jail: Robbery. Assault. Failure to appear for court. Theft. Domestic violence.

I don’t seek that information before I meet my patients in jail. If patients start sharing their understanding as to why they’re incarcerated, I stop them. My duty is to the patient, not to the court or the attorneys.

When I first started working in the jail, I looked up the charges for all of my patients, as that information has the potential to help with clinical care. What I saw quickly dissuaded me from doing this on a routine basis.

It is uncommon for a man of the Angel’s age to be in jail. Yes, he was reporting and demonstrating psychiatric symptoms, but they alone did not explain why he captured the attention of law enforcement. Why would a man with his gentle manner and feeble condition be in jail?

Failure to report: sex offender.

The Angel had two convictions: One for Rape, the other for Indecent Liberties With Forcible Compulsion. These occurred years apart.

“Sometimes God says helpful things,” the Angel answered. “Sometimes… not.”