Education Lessons Nonfiction Policy Reflection Systems

What I Learned in Government.

It’s been nearly four months since I posted something here. Don’t be fooled: The lack of words here did not mean an absence of word salads tossing about in my head.

I recently resigned from my job. (All The Things related to that contributed to my silence here.) My job had two parts: One involved administrative work as the behavioral health medical director for local government; the other involved direct clinical service in a jail. I was in that job for over five years. It took me about two and a half years to figure out what an administrative medical director does. (As the process of becoming a doctor involves frequently feeling incompetent, this discomfort wasn’t new to me.) Now that I’m on the other side of this job, here’s what I’ve learned:

I believe government can do good things. You know that stereotype that government employees are lazy? I did not find that to be true. Every organization has a proportion of staff who do not seem motivated or interested. The proportion, in my experience, does not seem higher in government. If anything, many of my colleagues came to government with eager hopes of improving the community. They came in early, stayed late, and worked on weekends. They convened groups with opposing viewpoints, advocated for different populations in the region, and expressed dissent to people in power. They sought out and willingly worked on complicated problems. They demonstrated the humility that comes with the realization that tax payers are funding their salaries.

I do not enjoy the game of politics. Some people love it! They enjoy the contests of status, flaunting their connections, and attacking perceived enemies in public forums with the brightest of smiles. Sometimes people asked me to speak, not because they cared about the content of my words, but because of my credential as a physician. (“Let’s trot out The Doctor.”) I grumbled about “perception management”; often it seemed that the surface sheen mattered more than the substance underneath. (On the other hand, it is likely that my glittery MD credential is what allowed me to say to superiors that poop will never develop a patina. It is unfair that systems often value specific people more simply because of the letters after their names.)

Government work has made me both more and less patient. It takes time to elicit ideas and information from “stakeholders”, community members, and others. People want to and should be involved if a policy or program will impact their lives. They share perspectives that government never thought to consider. I respect that process. I am less patient with the nonsense people and systems can generate to subvert fair processes. Some people are more prone than others to misuse power. That’s hard to watch in a system like government, which has access to and authority over so much money… and, in our current system, whoever has more money almost always has more power.

I learned a lot about laws and regulations. I came to appreciate the value of regulations, though they tend to address the lowest common denominator. Government spends most of its time aiming low to define the floor instead of inspiring people to elevate the ceiling. (I wrote more about this here.)

Government administrators forget what happens in direct service. Though many people in government once provided “front line” services—as attorneys, social workers, counselors, activists, whatever—many of them seem to forget the challenges of systems that are intended to help people. This includes the thousand little cuts of too much paperwork and the major crises of people dying due to missing or underfunded services. My opinion that all medical directors should routinely provide direct clinical service has only gotten stronger with this experience. Someone has to inform the others at The Table what’s going on outside.

Systems are made of people. Contemporary discourse often focuses on systems, not people… but people make up systems (i.e., individuals create, operate, and maintain systems). As such, single individuals can still have significant impacts on systems. This includes grinding things to a halt… or breathing life into new programs. (This is where political gamesmanship can be useful.) The hierarchical organizational chart can lead people who are “lower” to think that their efforts don’t matter, but that’s simply untrue. Systems can change because people can change… whether that’s because people actually change their ideas and behavior or people in certain positions leave.

I am deeply grateful for the opportunity to work in government. I never thought I would work as a civil servant (and, in fact, there was a time when I said I’d never work for government… which is why I’ve stopped making five-year plans). If for nothing else, now that I’ve been on the inside, I can use that experience and knowledge on the outside.

The outside suits me better. So it’s time to go back.

Lessons Nonfiction Reflection

Be Different and Do Better.

I didn’t know that he and I were on the same train. At the Othello stop, I got out of the last car and walked towards the front of the train. The morning chill seeped through my coat and I slid my hands into my pockets.

“Dr. Yang!”

The doors of the train were still open and there he was: A baggy black hoodie was pulled up over his head, but it did not conceal the wide grin on his face. He was leaning forward in his seat and waving his arm and hand at me like a little kid.

The doors were closing when I waved back. I was still smiling when the train whirred back into motion and passed me.

It was the gracious and respectful patient!

There were several men loitering outside the clinic, the red and yellow leaves of autumn scraping the sidewalk around their feet.

He saw me first.

“Hi! Doctor… Yang! It’s so good to see you!”

“Hi!” I greeted. He looked well, though the gaps between his teeth were wider now compared to when I last saw him.

The two men who were standing by him looked at me with curiosity.

“It really is good to see you,” he said, taking a step towards me. “Can I hug you?”

“No,” I said, “but we can bump fists.”

My fist met his in a gentle bump. One of the other men cocked his head to the side, his face perplexed. He slowly extended his arm towards me, his hand in a loose fist. My fist bumped his, too. His head began to bob in a slow nod as he kept his arm extended.

“I’m doing really good,” my former patient said. Over a year had passed since we had last seen each other. During his many months in jail, he had been under my care. “I’m off prbation! I haven’t been in the hospital in over six months! I have a place to live and I see my counselor here every week.”

“That’s fantastic!” I exclaimed. “I’m happy to hear that.”

“How are you doing?” he asked.

“I’m doing well, thank you,” I answered. He didn’t press further when I redirected the focus back onto him. “It is wonderful to see you out here and not in that other place.”

“Jail?” Oh well. I at least tried to keep that out of the conversation. “Oh yeah, I haven’t been in jail in a long time.”

“Which is good news. I’ve got to go inside to meet someone.”

“Oh, okay, Dr. Yang! I need to check in with my counselor, too. It really is nice to see you! Bye!”

Perhaps it is foolish to assume that people are inherently good. How can we believe that people are good when they burst into houses of worship to kill people? Why should we trust that people have good intentions when they send explosives in the mail? When people encourage violence against people who don’t share their beliefs, language, or skin color, isn’t it unwise to have faith in our fellow humans?

The charges filed against the two men described above weren’t trivial:

  • theft
  • criminal trespass
  • resisting arrest
  • assault

I shared a gentle fist bump with one of them. I know what injuries he had inflicted with that fist in the past.

And yet. And yet!

People ask me how often I encounter people who were under my care in jail. They ask me that question with concern; they worry that these chance encounters will lead to danger.

I see former patients from jail about once every one to two months. Most of the time, they see me first, greet me by name, and then go about their business. Sometimes they provide a short update about their lives. Sometimes they make a point of thanking me.

So is it truly foolish to assume that people are inherently good?

Let’s be clear: There are a few individuals who have been, are, or will be under my care who I do not ever want to see on the outside. If I do see them, I cross the street, duck into a building, or otherwise try to disappear. I trust that some of these individuals have probably seen me without my awareness. In those instances, ignorance is bliss and I am thankful that nothing transpired.

Things change, people change, circumstances change. Sometimes we look at the world around us and despair: People suffer, injustices big and small happen to the best of people, individuals we don’t like or respect collect more and more power.

And yet. And yet!

Consider the people in your life who inspire you to do good things. There are people you see and who see you: Friends, family, coworkers. They do things you admire; they say things that spark ideas; who they are makes you want to be different and do better. This happens to you every day.

Then consider the people in your life who you see, but they do not see you: Leaders, artists, and other public figures. Despite the absence of a personal relationship, they also inspire you to be different and do better.

Realize that there are people who you do not see, but they see you. You, too, can inspire others to be different and do better.

We may feel like we don’t have much influence, but we all have influence within the three-foot radii around us. We can choose to amplify the inherent good within us to help ourselves, others, and the world around us—even just the world within our three-foot radius—be different and do better.

Yes, the suffering and injustices continue, but if we do nothing, then we surrender to those who do choose to do something.

Many of these men in jail have and will continue to inspire me to be different and do better. Maybe they will inspire you, too.

Lessons Medicine Nonfiction Reflection

Centered and Ostensibly Serene.

The nights from that time run together in my memory: The cuffs of my scrub pants getting caught on the heels of my clogs because my pants were sagging; stuffing dry graham crackers I stole from the nursing stations into my mouth at 4am to stay awake while writing notes; what seemed like my pager buzzing against my hip every five minutes; feeling the enormous specter of unending work overtaking me and wondering if I had any remaining skills to gird myself; recognizing the sadness and anger churning within me as I witnessed and listened to tragedies, then shoving the emotions away because there just wasn’t any time I didn’t want to cry I just needed to get through a few more notes I just wanted to sleep of the mistaken belief that if I ignored how I felt, I would be okay.

“Hey, you! You coming to talk to me?” The Big Man shouted.

“No,” I replied. “I’m going to talk with your neighbor.”

“What? But then you’re gonna talk to me, right?”

“I have two other people to talk to first, but, yes, I will talk to you after I talk with them.”

“But you’re gonna talk to me, too, right?”


I had just finished introducing myself to The Patient and was asking his name when The Big Man, just three feet over and behind a reinforced steel door, started yelling at me: “You lying bitch! You said you’d talk to me!” The Big Man began pounding on the door with his big fist.

The banging reverberated throughout the entire unit. Another inmate on the other side of the unit began banging his door in protest.

I sighed and rolled my invisible eyes.

BANG BANG BANG “I’m sorry,” I said to The Patient. He nodded and came closer to his door. I did the same. “I will try to keep this short, but I do want to hear what you have to say.” BANG BANG BANG

BANG BANG BANG “It’s okay,” The Patient replied. BANG BANG BANG

BANG BANG BANG “Are you in any physical pain right now?” BANG BANG BANG

BANG BANG BANG He tilted his head, telling me without words that he couldn’t hear what I said. BANG BANG BANG

BANG BANG BANG “Are you in any physical pain?” I asked again, nearly shouting. BANG BANG BANG


BANG BANG BANG “My feet,” The Patient answered, raising his voice. “I have blisters.” BANG BANG BANG

He pointed down at his feet. The puffy blisters were evidence of ill-fitting shoes. The Patient reached down, grabbed a sandal, and threw it in the direction of The Big Man. BANG BANG BANG “Stop it, man.” BANG BANG BANG I watched it sail past me and bounce in front of The Big Man’s door.

BANG BANG BANG “Do you want me to get that for you?” I asked, recognizing that the pair of sandals were now separated. BANG BANG BANG

BANG BANG BANG The Patient chuckled. “No,” he answered, a small smile on his face. “I only had one, anyway.” BANG BANG BANG

BANG BANG BANG “Do you want another pair?” BANG BANG BANG


BANG BANG BANG “No, I’d rather have a pair of socks,” The Patient replied. BANG BANG BANG

BANG BANG BANG “I’ll get you a pair.” BANG BANG BANG

Despite the increasing rate and volume of The Big Man’s fist hitting the door, The Patient and I both ignored him. It was clear that we had both mastered this skill at some point earlier in our lives. The Patient made it look effortless; his face was calm and his voice was even. Even though he had thrown his shoe, his limbs did not become tense again.

The Patient told me about his health, asked me to call his counselor, and, when I ended our conversation only a few minutes later due to the noise, he thanked me.

BANG BANG BANG “No, thank you,” I said, smiling. “I appreciate your patience. I will try to talk with you again later. Maybe we will have better luck.” BANG BANG BANG

I didn’t look at The Big Man as I turned away. He stopped banging when I had walked a mere ten feet away from them. I then rolled my actual eyeballs. I knew that was when he would stop.

The stress of internship and residency most certainly contributed to my current abilities to stay centered and ostensibly serene in the midst of chaos. We all had to learn how to manage ourselves in the face of death, disease, and distress. Sometimes our efforts were successful; sometimes we felt embarrassed because we believed our efforts failed.

I learned how to show myself more kindness during residency. This wasn’t a conscious choice. Three things happened:

  1. In learning how to provide psychotherapy to others, I learned how to apply these skills to my own life.
  2. I couldn’t contain the sadness and anger that churned within me as I witnessed and listened to tragedies. Sometimes I cried in the bathroom. Most of the time I wept at home.
  3. People—and more often than not, patients—demonstrated grace and kindness during these moments of heartbreak. They often exhibited a capacity to accept their circumstances and show compassion, despite their physical or psychological pain.

I felt my chest fill with grief as I walked away from The Patient and The Big Man.

What happened to The Big Man? When and how did he learn the only way to get his needs met is to destroy silence?

What happened to The Patient? When and how did he learn to show grace and respect in the midst of hateful noise?

I didn’t cry because, this time, I didn’t shove the emotions away.

Lessons Nonfiction Reflection Systems

Phone Calls.

I don’t miss making the phone calls in the middle of the night.

“Hi, this is Dr. Yang calling from the Psychiatric Emergency Service. May I speak to Mr. or Mrs. Doe?”

“Yeah, this is Mr. Doe,” he’d reply, his voice thick and slow with sleep.

“I’m sorry to call so late. Your son is here at the hospital.” Take a breath and slow down for the next part. “He’s alive and doing okay at this moment”—I quickly learned that it is important to say these words at the start of the call—“but I hope to get some information from you about him.”

I have marveled at the grace people have extended to me during these conversations. Sometimes family members have grown accustomed to these 2am calls and their voices sound not only physically sleepy, but also psychologically exhausted. Sometimes family members have never received this phone call, but their voices remain calm with only the occasional quaver while they talk.

These days, it’s “Dr. Yang calling from the jail”. Though I’m not making these phone calls in the middle of the night, it is questionable that these are better phone calls.

It is a blessing when family members are still involved, when there’s someone I can call. The person in question is usually a male in his 20s. He often has reached desirable milestones: Maybe he just graduated from high school or is in college. His primary health issue is the mental health condition—often bipolar disorder or schizophrenia—and he’s otherwise healthy. He is often able to tell me about a family member who loves him, even if what he tells me doesn’t make a lot of sense in the moment.

For so many others under my care, there’s no one to call:

  • “They died.”
  • “I don’t want anything to do with them.”
  • “I don’t know where they are.”

Sometimes the person in question is much older. In some ways, these phone calls are more tragic:

  • “I’m in my 70s now and I’m the process of moving my wife into a memory care facility….”
  • “My husband has already died and I worry who will take care of my son when I go. He still needs a lot of help.
  • “Thank you for calling, Doctor, but it doesn’t seem like anything will change. I’ve been doing this for almost thirty years now.”

I marvel at the grace people have extended to me during these conversations, too. For some of these family members, they’ve had dozens of these conversations with many other doctors, nurses, counselors, and social workers. They know what questions I will ask; their answers are succinct because others have interrupted them in the past; they have lists of information already prepared to send.

Almost without fail, after I thank these family members for their help and then comment on the difficulty of the situation, they cry. Sometimes the sobs that escape their throats surprise them.

“I’m sorry,” they mumble. I can hear them wipe the tears from their faces with haste.

I’m sorry that we can’t do better for your son. I’m sorry that the science hasn’t advanced enough that we can prevent this from ever happening to your son ever again. I’m sorry that your son is in jail when he should be in a hospital. I’m sorry that your hopes and dreams for your son haven’t come true. I’m sorry that few people know the depth of the worry you have for your son. I’m sorry that these systems fail you and your son. I’m sorry that your love for your son isn’t enough to save him from these systems.

“Please, don’t apologize,” I say instead.

I wonder why.

Homelessness Lessons Medicine NYC Observations Reflection Seattle

The Kind of Energy We Send Out to the World.

I have been writing; I just haven’t posted anything here. These days, it seems that we cannot escape increasing types of noise and their loud volumes. It’s not all noise, but the signals are overwhelming.

It was a busy teaching week for me: I had the privilege to speak at two community clinics and a public hospital. In all three presentations I commented on the tension between “the system” and our efforts as individuals. When we’re trying to provide care and services to individuals, sometimes the constraints of “the system” interfere with our efforts: Sometimes fiscal concerns reign supreme; sometimes the bureaucracy is inflexible; sometimes the system does not have noble intentions. We grumble, we get angry, we feel helpless.

When we’re trying to design “the system” to provide care and services, sometimes the constraints of people interfere with our efforts: Sometimes there aren’t enough people; sometimes people make mistakes; sometimes people do not have noble intentions. We grumble, we get angry, we feel helpless.

The two, of course, are related: People design systems. People work within systems. People can change systems.

People also have values. Sometimes we find that our values clash with those of the systems we work and live in. That doesn’t mean that we must defer to the values of the system. It takes courage to resist. To show our values to the world without flinching is an act of bravery.

While speaking, I told a story about my first boss when I finally started working as an attending psychiatrist. Our jobs included working with people who were homeless in New York City.

“I want people who don’t have a place to live to get excellent care,” he said, perhaps talking more to himself than to me. “Good care shouldn’t be limited to people who can afford to pay a psychiatrist who works out of a plush office on Park Avenue. People who don’t have money should have access to and get good care, too.”

“These are choices under our control,” I said to the audience yesterday, perhaps talking more to myself than to them. “Even though system pressures are very real, you can choose to give good care to the people who come here for help. You can treat people with dignity and respect, particularly if they are people of color with very low incomes. They might not get dignity or respect elsewhere.”

Perhaps my exhortations sound naive. Perhaps cynicism will triumph over virtue. However, I refuse to embrace cynicism. Cynicism makes for terrible company. Life is already full of challenges; we do not need negative soundtracks to accompany us as we travel through life. What we do affects others. What we say can inspire others.

We have responsibility for the kind of energy we send out to the world.