Category: Lessons

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Homelessness Lessons Medicine Observations

Saying Good-Bye.

I originally wrote the post below over five years ago. It’s about a teenager I worked with for about six months at a residential treatment center. I still think about him from time to time; I hope that he was able to exit the mental health system.

A few months later, I learned that, less than 24 hours after we said good-bye, he injured himself while destroying property. He apparently threw chairs, punched walls, and tried to knock over bookcases and other pieces of furniture. There was no obvious trigger. It took four adults to subdue him. Staff commented that he had not behaved this way in over two years.

“That’s how he dealt with termination,” a staff psychiatrist murmured.

I’m still not sure if I agree with him.

I’m still not completely sure of the optimal way to proceed with termination.

Termination refers to the end of the therapeutic relationship between patient and physician (or, more specifically, psychiatrist). There are essentially three ways termination can occur:

  • Patient exits the relationship (patient stops attending appointments; physician fires patient; s/he dies)
  • Physician exits the relationship (s/he dies; patient fires the physician; physician disappears)
  • Patient and physician mutually agree on a final appointment date and time and complete the session

Ideally—for both parties—the last option occurs. This allows “closure”. And, no, I’m not entirely sure what comprises “closure”, but the lack of “closure” is why many break-ups suck. Think about it: Break-ups are uncommonly mutually agreed upon events; usually one party decides to unilaterally bail, resulting in negative emotions all around.

In therapy, we do not want to recreate break-ups; instead, we want to model and engage in the graceful end of effective and meaningful relationships. (Psychobabble.)

Saying good-bye is difficult. The white coat-wearing medical doctor within the psychiatrist bristles at the idea of termination; there is something about our medical training that promotes the idea (“virtue”?) of emotional distance and independence from our patients. So many things about our profession (both intentionally and unintentionally) facilitate this: Doctors wear white coats. Doctors wear gloves. Doctors ask a lot of questions, but rarely answer any. Doctors aim for objectivity and evidence.

So when we psychiatrists terminate with patients, the experience is weird and we are often surprised with how difficult it can be.

It’s never too early to initiate termination, so I had informed the adolescent male three months prior to our last appointment together that our time was drawing to a close. At the time, Andrew said nothing.

It’s not that he didn’t have anything to say about it; I had learned by this time that he heard practically everything I said, even though his behavior often purposely suggested that he was ignoring me.

A month prior to last our last appointment together, I reminded him again of my departure.

“Have you seen that Geico commercial? You know, the one with the little kid imitating a monster?” he replied.

As the days passed, he spontaneously mentioned the limited time we had together, though he tossed his remark within a smokescreen:

“I can’t believe that happened; it kinda makes me sad. You and I have three sessions left; we have to make the most of them. So I think I am going to try asking her again, maybe when she’s not so depressed, but it’s hard to tell….”

And that’s the way it had been the entire time we spent together; he would share bits of himself—often only a sentence here, another one there—at random intervals. Sometimes he would acquiesce if I asked a few questions to clarify his remark; most times, he simply changed the subject. One day, I called him on it.

“You’re really good at changing the subject when I ask you questions.”

“Yeah, I know,” he nonchalantly conceded, “I don’t like it when people care about me. It makes me feel weird.”

And when I tried to ask him more about that, he promptly commented on the weather. I smiled—sadly—at him.

The last time I saw him, he greeted me warmly.

We learn in the course of our training that therapeutic termination includes reviewing the time spent together and commenting on progress and goals attained. It’s like a summary statement, an opportunity to reflect upon how the patient has changed and how the patient can continue to effectively pursue his goals.

I already anticipated that, though he would hear my monologue of the above, he would not respond. My hypothesis bore true.

I commented on our very first meeting and what he stated were his goals at that time.

“Did I tell you the joke about the buffalo?”

I continued to commend him for the significant progress he had made in several spheres.

“What did the mother buffalo say to her kid as he left for school?”

I then reiterated his strengths—he had so many: he was so good with people; his integrity was admirable; he was intelligent and thoughtful; he was fiercely independent and more than capable of taking care of himself.

“Bi-son!”

I expressed my hope to him that he would continue to pursue his dreams—I was (and still am) confident that he could reach all of them.

“How about the one about the cowboys?”

I looked at him, willing him to participate in the conversation—but I knew saying good-bye was not his strong suit. His parents had abandoned him when he was young; there was no such thing as a “healthy” good-bye in his experience.

“Because they are too heavy to carry! HA!”

“Take care of yourself,” I said, patting his shoulder. “Good-bye, Andrew.”

He had already started to walk away when he answered, “All right.”

I watched his lanky figure amble down the hallway. I then quickly turned to go.

Categories
Education Lessons Nonfiction Observations

Daily Schedule: Geriatric Adult Home.

A sample agenda as the consulting psychiatrist at a geriatric adult home:

8:20am. Arrive at the concrete building. Wave through the locked glass door at the woman sitting behind the desk. She pushes a button and the door buzzes. Pull the door open. Say good morning. She never sounds cheerful when she replies, “Good morning.”

Because there is no open stair access, take the elevator up one floor. It travels slowly. The doors slide open on the second floor with the speed of a clam.

8:25am. Walk past the dining room. Many of the residents are eating breakfast. Silverware clinks against plates. Few people speak to each other. Some people make eye contact and nod hello. Some stare.

8:30am. Walk into the main office and into the recreational supply room. Sit down at the old desk and log into the computer. Stand up and arrange two chairs so that they are facing each other at about a 45-degree angle. During the summer, turn on the window air conditioner. In the winter, keep a sweater on.

Review the daily schedule and skim notes from the previous patient visits. Look over any notes from the consulting primary care physician. He’s an infectious disease doctor. He’s kind and intelligent. Make notes about what to discuss with each patient.

9:00am. First patient[1. All patients described here are composites of people I have seen across time.] arrives. He doesn’t like to take psychiatric medication, but, for unclear reasons, continues to do so. As usual, he plans to walk about sixty blocks for exercise, but only along the major streets and avenues so that the government agents won’t try to kill him. He decides to wear a red necktie today to communicate to the agents that he knows they are monitoring him.

Scribble notes for the documentation later and schedule a follow-up appointment as needed. This happens after each meeting with a patient.

9:30am. Second patient arrives. Staff called for an ambulance two nights ago because he was disoriented and wearing pants on his head. He had bought three bottles of cough syrup from the bodega and drank them in one sitting. The emergency room released him and told him to stop drinking cough syrup. He bought three 24-ounce cans of beer this morning. He has only drank one so far. He doesn’t think there is a problem.

10:00am. Third patient hasn’t arrived.

10:05am. Third patient still hasn’t arrived.

10:06am. Call the front desk. The Woman Who Never Sounds Cheerful confirms that the third patient is in the building.

10:07am. Climb up two flights of stairs. Pass an elderly man who is slowly walking down the stairs, one arm holding the railing, the other an aluminum cane.

10:08am. Knock on the door of the Third Patient’s apartment. No response after 10 seconds. Knock again.

10:09am. Third patient answers the door. She forgot the appointment. Her memory is failing her. She points at a chair. She sits on her bed, the linens neatly folded. She plans to go to the adult day program today. Her dentures bother her, but she’s due for a size adjustment next week. She shows you the magazine pages she has taped to the wall: Whitney Houston, Michelle Obama, and Ella Fitzgerald.

10:27am. Return to the recreational supply room. Passed the fourth patient on the way back in.

10:29am. Fourth patient wants a tranquilizer, the kind that can induce mild intoxication. He talks about dirty liberals withholding medications from him. He hasn’t showered in about two weeks and wishes people would stop asking him about this. He doesn’t think he needs to clean his room, but rats have been nibbling at the leftovers he leaves by the bed. He doesn’t like that.

11:00am. Fifth patient just got back from a computer class. She is attending a talk this afternoon at the community center and plans to enroll in swim classes. On lower doses of medication, she smashes all of the mirrors in her apartment because Satan tries to kill her through the mirrors. She never talks about medication.

11:30am. Meet with the social work staff. Discuss possible new referrals. Also discuss patients who may benefit from visits in their apartments, as they may not be able to come to the office directly. Provide consultation on difficult interactions between staff and patients, and amongst the residents themselves. Talk about the weather, cookies, and news.

12:15pm. Lunch.

12:35pm. Begin writing clinical notes. Call a hospital to ask for an update about a patient. Review client list for the afternoon.

1:00pm. Sixth patient says he hates doctors. The primary care doctor won’t give him more pain medications, the psychiatrist probably thinks he’s crazy when he’s not, and the dermatologist doesn’t listen to him. For someone who hates doctors, he is always early to his appointments, has never missed a visit, and has to be assertively walked out of the room.

1:30pm. Seventh patient hasn’t arrived.

1:35pm. Seventh patient still hasn’t arrived.

1:36pm. Social worker thinks that the seventh patient is in his apartment.

1:37pm. Climb up three flights of stairs. Knock on patient’s door. He says, “Come in.”

1:38pm. Seventh patient is sitting in a chair. An open box of cereal and a nearly empty two-liter bottle of soda is on his nightstand. He hasn’t left his apartment in three days, even for meals. He hasn’t taken a shower in five days.

“The food is my body,” he says. Efforts to challenge this belief are unsuccessful.

“I don’t want to eat my body.”

He has been accepting antipsychotic medication over the past week. He doesn’t object to a higher dose of the medication. He learns that the dose will increase tonight and that staff will knock on his door before each meal to encourage him to come downstairs to eat.

1:55pm. Tell the social worker about plans about the last patient. If his condition worsens or he stops eating completely, he should go to the hospital for possible admission.

2:00pm. Eighth patient arrives. She hasn’t smoked any cigarettes in 12 days! She also, as ordered, stopped taking the antipsychotic medication about three weeks ago. The medication was tapered off over four months. She occasionally talks to herself, but this does not distress her. She reports feeling more energy. She also has a medical appointment in three days; she appreciates the friendly reminder.

2:30pm. Ninth patient arrives. He and his girlfriend are going through difficulties. He doesn’t know how to handle the situation; he’s not sure if he still wants to date her. He realizes that he is only getting older and thinks that he probably won’t ever date anyone ever again. He wonders if this is all he will ever experience.

3:00pm. Tenth patient arrives. He just moved into the building; he was just in the hospital a few weeks ago. He’s taking a high dose of an antipsychotic medication; if he stops taking medication, he soon believes that he will develop STDs from the people around him. This causes him to scream at people and throw things at them. He used to play the trombone and says that he makes a tasty lasagna. He hasn’t drank alcohol in twenty years. He’s glad to be out of the hospital and wonders if the building serves good food.

4:00pm. The eleventh patient won’t remember her appointment, so the meeting occurs at her apartment. The only furniture in her room is her bed, though there are no linens on it. The unfolded cardboard box is on the floor. That is where she has slept for the past five years. She is losing her sight, but she still applies lipstick every morning. She thinks the bricks in the building contain body parts of aliens, so she doesn’t want anything to touch the walls. She doesn’t want to take any medications, but she’s willing to attend appointments in the future.

4:30pm. Close the door to the supply room. Return phone call and speak to the hospital psychiatrist about a shared patient. Call grandson of the man who isn’t eating to provide an update and to help coordinate care. Leave a message for the primary care doctor about the woman who has stopped smoking.

4:50pm. Type up notes from the day.

5:30pm. Log out of the computer and walk out of the office. People are eating dinner, but the man who thought he was eating his body is not present. Take the elevator downstairs, and walk past the front desk, now manned by a person who regularly smiles. No one on the busy avenue outside knows what happened in the building earlier in the day.

Categories
Lessons Medicine Nonfiction NYC Observations Seattle

Doctor as Patient.

It had been about two years since I last saw a primary care doctor. I was still living in New York City. My initial—and only—appointment with that physician lasted nearly an hour.

The front desk clerk had a round, pale face. Behind her was a textured wall over which ran a thin sheet of quiet water. Lush leaves spilled over the brim of the planter onto the marbled countertop.

“I’ll let the doctor know you’re here,” she nearly whispered.

He was a family practice physician. He was friendly. He smiled at me. He asked me if I lived in the city. When he learned that I worked as a psychiatrist, he commented, “Wow. That’s hard work, Dr. Yang.”

It was professional courtesy to address me by that title, though it didn’t feel right to me. I looked down to mask my discomfort. My feet dangled off of the examination table.

“Do you have a private practice?”

No, I said. I worked primarily with people who were homeless.

“Oh,” he said. “That’s even harder work.”

He asked me about my medical history, then my family history. He went through the major components of a physical exam.

He told me about his work as a primary care doctor. As a physician in primary care, it was getting more difficult to stay in business. He previously worked in New Jersey, but had been practicing in New York for a few years. He didn’t think he would leave the city. He was established now.

His technician then put square stickers on my chest and the EKG machine printed out my heart rhythms. Next, I took a deep breath in and held it as another technician took a chest X-ray. And then, another technician, who apparently worked as an anesthesiologist when he was living in his native country, told me not to worry too much when he drew my blood.

“It won’t hurt at all,” he snickered.

The physician called me two weeks later. He said that everything looked fine.

My primary care appointment in Seattle was one of the first visits of the physician’s day. I walked into the medical center and looked at the directory. I must have looked perplexed. A portly man with glasses asked, “Can I help you find something?”

“I’m looking for Dr. X’s office.”

“Fifth floor.”

Dr. X wasn’t a physician in private practice. Are there even family practice doctors in private practice in Seattle? I wasn’t sure how long the appointment would be. Not long ago, I was working with primary care physicians who had appointment lengths of 20 minutes. I envied them. I only had 15 minutes with each patient. A lot could happen in those extra five minutes.

The medical assistant was wearing a plaid shirt and black high-top sneakers. I couldn’t help but think that no medical assistant would dare wear anything like that in New York.

He left me alone in the exam room and I waited. It was a cold room and the gown was thin. I hoped that my doctor wouldn’t be harried and rushed.

After the physician knocked on the door, she quickly entered and gently shut the door behind her. She was about my age. She wore a long white coat and her stethoscope was around her neck. I immediately thought of the snarky comment one of the surgery residents had made about internists when I was a medical student:

“They wear their stethoscopes like they’re dog collars.”

“Hello, Ms. Yang—Dr. Yang? Dr. Yang, right?”

“Yes,” I said. There was that professional courtesy again.

She didn’t ask me many questions. I had filled out the general health questionnaire prior to the visit; she reviewed my responses. She typed some notes on the computer while we talked.

With what seemed like some sheepishness, she provided counsel on vitamin D. Maybe she thought that I was already aware of this. Maybe she thought that she shouldn’t go on about it because I had resources to look it up myself. Maybe she didn’t want to seem condescending. I couldn’t help but think, Don’t worry about me—just do your job. I don’t follow vitamin D as closely as you do, just as you don’t follow schizophrenia as closely as I do.

She went through the major components of a physical exam. We soon were talking about her job.

“Yeah, I went to a Prestigious Residency, but it really was malignant,” she said, pushing on my abdomen. “I’m so glad that I have this job here.”

“Do you mind if I ask about any productivity requirements you might have?”

“You may not believe this, but my schedule is built so that I only have seven patients scheduled in the morning and seven in the afternoon. I can add more on, but that’s the general schedule. That gives me time to call patients, return e-mails, and spend more time with geriatric patients, since, you know, they often have a lot of health problems and need more time.”

I was silently doing the math in my head. Seven patients for an entire morning! There were days when I had seven patients scheduled in two hours!

“Yeah, I can’t imagine working like that,” she said.

She spoke quickly after she completed the exam. “If you have any questions, you can call me or send a message through the website. It was nice to meet you.”

As I was getting dressed, I found myself wondering about all the tests she could have done, but did not. Wouldn’t it have been nice if she had baseline studies for me? What if I developed an arrhythmia in the future? Wouldn’t a previous EKG be useful for that? And what about basic labs? What if my kidneys start to peter out? Wouldn’t it be nice to know that they were fine in 2012?

And then I caught myself. Most women my age are healthy and without medical problems. I hadn’t endorsed any symptoms that would warrant further intervention. Tests had their risks, too.

Doctor as patient. I considered myself lucky that I was able to leave without new diagnoses or the need to return within a few weeks.

And I remembered again what it was like to be a patient.

Categories
Education Lessons Medicine Nonfiction Observations

An Open Letter to All the Patients I Have Ever Cared For.

Originally written during my second year of residency. Now that I am an attending, I believe more than ever that patients “are our best and most effective teachers”.

Dear Patient(s),

Thank you for educating me.

Thank you for letting me shine bright lights into your eyes and place Q-tips up your nose. Thank you for not shooting me a dirty look when I ask you to lift up your pendulous breast so I can listen to your heart. Thank you for letting me ogle at your protuberant belly—whether it contains a baby, a liver tumor, or liters of fluid inside. Thank you for not experiencing an erection and for refraining from snide remarks when I examine your penis. Thank you for telling me that my speculum use is suboptimal and has caused you pain during your pelvic exam. Thank you for nearly kicking me in the face when I tap on your knees to test your reflexes. Thank you for peeing all over me after I remove your diaper.

Thank you for answering questions that, in any other context, are completely obnoxious and rude. Thank you for being honest with me when I ask if you are a prostitute, an IV drug user, or an alcoholic. Thank you for not assaulting me when I ask if you have sex with “men, women, or both”. Thank you for answering questions about hearing loss when you’re actually concerned about your chest pain. Thank you for not yelling at me in impatience when your back pain is “a ten out of ten”.

Thank you for telling me that it doesn’t seem like I am taking that symptom seriously. Thank you for not masking your facial expressions and allowing your face to contort in offense when I phrase a question or statement poorly. Thank you for saying “OW” when I do something that causes you pain. Thank you for screaming in my face for the duration of our time together after I look into your ears.

Thank you for letting me wake you up at 4:30am for the sole purpose of allowing me to examine your belly wound. Thank you for letting me wake you up at 8:30am, a mere ten minutes after you fell asleep after being up all night and writhing in agony in the ER. Thank you for asking me if I could get your a cup of water or ice chips. Thank you for reminding me that your thirst matters more to you right now than the fact that your potassium level is uncomfortably low.

Thank you for apologizing when you throw up all over yourself—not that you should, but your mindfulness in that moment illuminates a strength that you have that I don’t know that I would have in that moment. Thank you for crying in front of me. Thank you for sharing your deepest fears with me. Thank you for asking me to leave so you can spend time with your family, all of whom are devastated with your prognosis. Thank you for asking me to sit with you. Thank you for asking me to listen. Thank you for reminding me that sometimes, being present with patients is more important than writing for another antibiotic.

Thank you for answering questions that you have already answered for five other people. Thank you for not yelling at me when I ask the same question twice in the same interview. Thank you for refraining from comments like “You’re totally imcompetent” when attending physicians have brought up a diagnostic or therapeutic possibility that I had completely overlooked (or just did not know). Thank you for not spitting in my face when all I seem to say is “I don’t know”. Thank you for not throwing things at me while I nod off when the attending physician is speaking to you.

Thank you for telling me that you have thought about killing another person. Thank you for your attempts at pushing my buttons, whether it be through questioning my technical knowledge, academic status, or medical specialty. Thank you for sneering at me.

Thank you for calling me “doctor” when I don’t feel like one at all. Thank you for saying “thank you” when you’re getting better—in spite of me, not because of me. Thank you for poking fun at me for the express purpose of making me laugh. Thank you for giving me a hug before you leave the hospital. Thank you for smiling at me.

Medical school and residency training involves a lot of reading, tests, and studying. But the truth is, you are our best and most effective teachers. And for that, I thank you.

Sincerely,
Maria

Categories
Lessons

More Encouragement.

Sometimes we get worked up about things that haven’t happened yet because we think about Everything That Could Go Wrong.

After we magically transport ourselves into this terrible version of the future, we convince ourselves that we will never, ever recover.

Or that the horrible conditions will never change. We have no doubt that we will have to endure pain and suffering forever.

Or maybe we become positively sure that we will lose everyone and everything that we value in our lives. How could we ever repair that damage?

Well.

How easily we forget about all the disastrous events and choices of the past that we have survived! We have all endured Terrible Things that no one else knows about. People look at us and we seem Okay, maybe even mildly amused. They have no idea.

Our recoveries may not have been easy. They may have taken much longer than we would have liked.

And, somehow, we made it. Those experiences shaped us into who we are today. We developed skills and talents that allow us to help other people now. When future calamity strikes, we are better equipped to deal with it, whether we have faith in ourselves or not. We might even have a sense of humor about it.

We become better people.

We worry now because we have hope for the future. The odds are in our favor that we will survive the crap that life will inevitably throw at us.

We will all be Okay.