Category: Lessons

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Consult-Liaison Education Lessons Reflection

Being Right vs. Being Effective.

“It’s best to avoid confirming their beliefs,” they said, “but you can validate the underlying emotion.”

She was dabbing her eyes with a crumpled tissue already streaked with mascara.

“It’s been two years and I still can’t believe he’s gone. I thought we would grow old together, that he’d get to see his kids graduate from high school.”

“The sadness still feels overwhelming.”

“Yes,” she whispered before bursting into tears. “When will I stop feeling so sad?”

He avoided eye contact while his leg bobbed up and down.

“I feel so anxious, like I’m paranoid. It used to be that I only felt paranoid when I was high on crystal meth, but now it’s all the time. It’s like people are watching me all the time, like they want to know all my business or something.”

“It’s exhausting to feel so anxious all the time.”

“Oh my God, YES. I’m so tired, but I can’t relax.”

“I didn’t know what to say to my wife. She didn’t deserve any of this. I tried to stop, and I did for a few weeks, but then I’d download more of it. My wife was the one who answered the door when the police came to seize my computer. I would do anything to not have this problem; I know how many people it hurts.”

“You feel a lot of shame about looking at child porn.”

His face flushed and his voice quivered.

“Yeah.”

She heard every word, but her gaze was fixed to something on the other side of the room.

“I can’t. I’ve already said too much. I can’t. I can’t. They know, they will know, they already know everything. I can’t. It’s in the lights, it’s in the ceiling, it’s in the sky. It’s everywhere. I can’t. They will know and they will know through the lights—”

“You’re scared that something bad will happen if you tell me the story.”

“Yes! And I want to be strong, I don’t want to be scared.”

“The whites are better than the Asiatics—”

“Let me ask something else—”

“—and there will come a day when all the races will submit to us—”

“—I’m going to walk away if you keep talking about this—”

“—even people who went to a lot of school like you. I’ll remember that you were helpful, but you are still just an Asiatic—”

“—okay, I’m going now.”

“But Doctor! You know what I say is true! C’mon! Why won’t you talk to me about this? You’re not being a good doctor….”

“You also have to respect your own limits,” they said. “Sometimes you want to show that just how right you are, but it’s much more helpful to be effective. And sometimes it’s best for everyone if you end the conversation when you’re no longer effective. You can always try again later.”

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Education Lessons Medicine Nonfiction Reflection Seattle

It’s Good to be Busy.

It was a busy day:

There was the guy who spoke with enthusiasm about his doctrine of RUL (“Righteous Unconditional Love”); the man who stared through me after I asked him about whether he had eaten that morning; the fellow who made no efforts to hide his nose-picking while expressing his frustration with the court system; the young man who wouldn’t let me inspect the wound on his hand, though I soon recognized that he had crafted the wound out of a packet of juice crystals; the man who hadn’t taken a shower in several months, though the odor bothered me more than it bothered him; the guy who boasted about his abilities to run a mile in two minutes; the man who refused to acknowledge my existence; the fellow who advised me that he would prefer to take his medications in the morning because that’s what his nurse practitioner told him to do; the man who apologized for masturbating, but argued that he is young and “that’s what young people do”; the fellow who said that after he used “bad heroin”, he realized that his parents aren’t actually his parents; the guy who found lithium energizing and was in the process of tapering off of methadone; and the man who simply said, “I’m not sick,” when I asked him why he hadn’t been taking medication that the state psychiatric hospital had prescribed to him. Nurses paged to ask for orders for medications to reduce the discomfort of heroin withdrawal, medications that patients had asked for three days ago, medications that patients took before they entered jail. The phone rang as callers shared information about diagnosis, treatment, and next steps.

I tipped my head back in the chair, stretched my arms up, and sighed.

“You okay?”

It was my second year of residency and I was the only psychiatrist in the hospital that night. My duties included addressing any issues that occurred in the psychiatric unit and providing care for any patients that came to the emergency department with psychiatric concerns.

My classmates had warned me about a particular emergency medicine attending physician who was working that night:

  • “Last week he told me I was useless.”
  • “He rolls his eyes at me all the time.”
  • “He’s just angry. He won’t ever thank you for anything you do.”

“Hi, Dr. Angry,” I said around 7pm. “I’m the psychiatry resident on call tonight.”

After glancing at me, Dr. Angry grunted.

Well, I guess that’s how it’s going to go tonight.

Less than three hours later, after Dr. Angry referred four patients to me, he muttered in my direction, “I’ve got another one for you.”

Shortly after midnight, a patient’s husband was pulling her out of the ED while she was screaming at me.

“I’M GOING TO GET YOU FIRED FROM HERE! YOU’RE A TERRIBLE DOCTOR! I KNOW THE PRESIDENT OF THE HOSPITAL! YOU CAN’T DO THIS TO ME!”

I was shaking, but I wasn’t going to admit her to the hospital. Dr. Angry caught my eye and nodded once. I wasn’t the only person who knew I was shaking.

It was close to 3am and I had already seen seven patients.

Dr. Angry had a slight smile on his face as he approached me while I was slogging through my notes.

“Dr. Yang, there’s another one for you to see.”

please make it stop

“Thank you. Who is it?”

As I was beginning my note around 6am for the ninth patient I saw, Dr. Angry stopped by.

“Dr. Yang, you did all right. Thank you.”

“You’re welcome, Dr. Angry.”

I tipped my head back forward in the chair in the jail and dropped my arms.

“Yeah, I’m fine,” I replied to my colleague. “It’s busy, but it’s good to be busy. And when I think about my intern year, this isn’t bad at all.”

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Education Lessons Medicine Reflection

Talking About Suicide.

I was recently asked to speak at a community event about youth suicide. Several young people in the area had killed themselves in the past few months to years. This was an opportunity for the community to learn and talk about suicide and suicide prevention.

My role was to provide a professional perspective on and information about suicide in young people. There was also a panel of people between the ages of 16 and 19 who shared their perspectives about suicide. The youth panel was the most compelling aspect of the evening.

The audience was comprised entirely of adults. Most were probably parents; others were adults who often interact with young people, such as school administrators and police. The youth panel encouraged the audience to talk to the young people in their lives about death, dying, and suicide. The panel also spoke about the importance of showing that they, as adults, care about young people. They shared their experiences in how talking about suicide with their peers has given others hope and saved lives.

One girl shared an anecdote that involved a teacher who inspected the wrists and arms of students prior to a test. He wanted to ensure that students didn’t have accoutrements on their arms that could contribute to cheating. This girl said that she felt anxious about rolling up her sleeves because of the scars on her wrists and arms from cutting. What would her teacher say or do?

When he inspected her arms, he undoubtedly saw the scars. His response? “Okay, good. Nothing on you that will lead to cheating.” And that was it. He never spoke to her about what he saw; he never asked her how she was doing or what the injuries were on her arms.

What did she take away from that? “He cared more about whether I was cheating than about me staying alive.”

The fresh candor of young people inspired some adults to comment on their own perspectives of suicide. One man, hands stuffed into the pockets of his jeans and voice deep and gruff, shared, “I’m a veteran. I also come from a generation of men who just don’t talk about suicide, even though a lot of veterans come home from war and commit suicide.”

The contrast was striking: The young people sat on the stage, the lights on their faces, and spoke about death and suicide without fear or self-consciousness. The adults sat in the shade of the auditorium and shifted with unease, gasped with sadness, or shook their heads when they heard the youth talk about their peers dying.

I do not believe that there was anything anomalous about this group of young people. Youth want to talk with adults about death, dying, and suicide. They want relationships with parents and other parental figures where they can ask questions, share their worries, and learn how to navigate the difficulties in life so that they can live another day. They also are sensitive to the burdens that adults already experience; sometimes they don’t share their thoughts, worries, dreams, and fears with us because they don’t want to cause us more distress. Because they automatically assume that any conversation about death and dying will cause distress in adults.

I created a short handout with suggestions about how to talk about suicide with young people (hint: these suggestions work with adults and older people, too). It also has phone numbers to call, online chats to access, and websites to view for more information about suicide prevention.

There is no evidence to support the fear that talking about suicide—particularly in a thoughtful, caring way—will increase the likelihood that people will kill themselves. In fact, talking about suicide directly can help people change their minds about taking their lives.

Here’s the requisite link to the National Suicide Prevention Lifeline, which is an excellent and literally lifesaving resource. However, I encourage all of us to talk with each other, within our own communities—even if it is “only” the community within our homes—about death, dying, and suicide. We don’t have to talk about it all the time; we don’t have to ask each other, “Are you thinking about killing yourself?” every day. The more comfort we have with talking about how we are doing, what we’re thinking about, and what death means to us, the more we can support each other when the difficulties, problems, and failures in life occur.

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Informal-curriculum Lessons Medicine Nonfiction Reflection Seattle

Crossing Streets.

I didn’t mind that I had to wait to cross the street. The yellow-white light of the Spring sun shimmered in the infinite depths of the lapis lazuli sky. The afternoon breeze lifted the fragrance of sweet flowers over the concrete and fluttered the short sleeves of my summer blouse.

Then I heard a man. He seemed to aim his voice, full of gravel, towards me.

“WOOOO WHEEEE!” He chuckled. “Lawd have mercy!”

ignore him don’t turn your head ignore him don’t look ignore him stay still

My peripheral vision saw his tall figure approach me before I heard him: “Doctah!”

okay he is probably talking to you take a breath

I turned. Though his pants, tee shirt, and jacket were all too large for his frame, it was a stylish look on him. His baseball cap was on backwards and pinned his dreadlocks away from his face.

“How you doin’?” he greeted, his smile revealing several missing teeth. He extended his right fist, a wordless invitation to extend my fist for a bump.

“So what are you supposed to do when you see your patient out in public?” We all looked at the professor with great expectation.

“What do you think?” (Of course a professor of psychiatry would answer a question with a question.)

“Well, you want to respect the patient’s privacy, so you probably shouldn’t say anything.”

“But what if your patient sees you first? And says hi?”

“It seems rude if you don’t say hi back. But if your patient is with another person, that could get awkward fast. What if the other person says, ‘How do you two know each other?'”

“I’d probably go out of my way to avoid my patient. I’d cross the street or something.”

“But that’s weird, too. Your patient might wonder why you’re avoiding them.”

“Or my patient might appreciate that I am keeping the boundaries clear.”

“If my patient said hi to me first, then I would probably say hi back and then try to get away as soon as possible.”

“What do you think they do in smaller communities? Doctors and patient see each other all the time when they shop for groceries and stuff.”

“That might be embarrassing: I don’t want my patients seeing me in sweats when I’m shopping for food.”

“Why are we assuming that patients would want to talk with us in public, anyway?”

The group reached a consensus: If you see your patient, but your patient doesn’t acknowledge you, don’t acknowledge them. You have a duty to keep things confidential. If your patient says hello to you first, be a person and say hello back, but keep it superficial and brief. And the next time you see each other, ask the patient how s/he would like to proceed in the future if you two run into each other again.

“I hope I never run into my patients,” someone mumbled.

The most memorable patient run-in I’ve had in a public setting occurred on a bus.

I was sitting in the back half of a double-length bus. Most of the seats were occupied and a few people were standing in the aisle. The grassy trashy odor of marijuana wafted from the rear of the bus. A young woman, who was under my care several times at a crisis center, and a young man boarded the bus. She saw me first.

“Hey! Doctor! How you doing?” she shouted at me. I nodded back at her. The older woman sitting next to me shot a glance at me, then sighed.

The young woman grabbed the young man’s hand and pulled him down the aisle. The two or three people ahead of them had no place to sit, so they halted and turned around. The young woman was thus about six feet away from me; she couldn’t get any closer.

As the bus lurched into motion, she leaned around the two or three people and raised her voice over the rumble of the engine: “Hey, Doc! I’m doing better these days! I haven’t been to the crisis center in like a month!”

“That’s good,” I replied. Maybe this will be the end of the conversation.

“I still take the Seroquel and Depakote now,” she continued. “Those meds really help. I take them every day.”

There was no street for me to cross. Okay, I guess this is really happening.

“But the meds are expensive! I want to keep taking them, but they cost a lot. Do you know where I can get meds for cheap?” Her eyes were eager.

The older woman sitting next to me heaved another sigh and closed her eyes.

Okay, if we’re going to do this, let’s really do this, then. I took a deep breath.

“Target has a four dollar list and those medications might be on that list. So, best case scenario, each medication will only cost $4 a month. Costco also has medications for cheap, sometimes medications that aren’t on the Target list. You don’t need a membership to use the pharmacy there.”

“For real? I can get medications at Costco without being a member?”

“Yeah. It’s a good deal.” Maybe someone else on the bus can use this information, too.

“Okay, cool. Target and Costco. Thanks, Doc!” She turned to the young man and began planning where they would get food for dinner.

As I stepped off the bus a few stops later, she called, “Bye, Doc! Thanks again!” I smiled and waved.

“Hi!” I said to the man with the gravel in his voice. you look familiar but how do I know you jail yes you were my patient in jail and what is your name what is your name wow you look so different but of course you do because you’re wearing regular clothes and you’re smiling and you’re outside on this beautiful day

I extended my right hand. We bumped fists.

“I’m doin’ real good, Doc. I take my meds every day and I live here.” He pointed to the handsome brick building down the street. “I ain’t picked up in a while and I’m takin’ care of myself. Things are good, Doc.”

“I’m glad to hear that.” I smiled.

“How you doin’?” he asked again, the gravel rattling in this throat.

“I’m well, thank you.”

“Well, you have a blessed day and you take care of yo’self!” He laughed and pointed at me while he walked away.

The white walking man appeared on the traffic light. I crossed the street. I was still smiling.

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Education Informal-curriculum Lessons Medicine Observations Reflection Systems

Thoughts on the Movie “Get Out”.

Have you seen the movie Get Out? If you haven’t, what follows might spoil part of the movie for you. You might want to watch it before reading this.

If you have seen Get Out, this post ponders the role of psychiatry in the movie. (Full disclosure: I enjoyed and recommend the movie.)

We learn early on in the movie that Rose’s mother is a psychiatrist. Chris, Rose’s boyfriend, asks something like, “She’s a psychologist?”

The response Chris receives is something like, “No, she’s a psychiatrist.”

While I can’t know for sure, I believe that the writer of the film, Jordan Peele[1. If you are not familiar with Jordan Peele, please go watch some clips of Key and Peele.], wanted to highlight the difference between the two. Psychiatrists are physicians. And some physicians, under the guise of expertise, have promoted racist ideas.

Dr. Samuel Cartwright was a physician who practiced in Alabama, Mississippi, and Louisiana in the years leading up to the American Civil War. He defended slavery and wrote pieces that argued that blacks were inferior to whites.

One of his articles, “Diseases and Peculiarities of the Negro Race“, describes “drapetomania, or the disease causing Negroes to run away”. Because he describes drapetomania “is as much a disease of the mind as any other species of mental alienation”, it is clear that this is a psychiatric condition, such as kleptomania (compulsive stealing), pyromania (compulsive fire-setting), and dipsomania (the old name for alcohol use disorders).

In this article Dr. Cartwright asserts that God has ordained blacks as “submissive knee-bender[s]” and are “intended to occupy… the position of submission”. To support that blacks were destined to be “submissive knee-benders”, he states that “in the anatomical conformation of his knees, we see [it] written in the physical structure of his knees, being more flexed or bent, than any other kind of a man.”

To prevent the development of drapetomania, he states:

if his master or overseer be kind and gracious in his hearing towards him, without condescension, and at the same time ministers to his physical wants, and protects him from abuses, the negro is spell-bound, and cannot run away.

In Get Out, Chris (plus Georgiana, Walter, and Andrew) becomes obviously “spell-bound” through the hypnotic powers of the porcelain cup and silver spoon. One could argue that Rose is demonstrating faith in this practice as she was initially “kind and gracious”, “without condescension”, “ministers to his physical wants”, and “protects him from abuses” (remember the police officer who pulled them over?).

Dr. Cartwright comments that, in the course of drapetomania, slaves become “sulky and dissatisfied” before they run away. He advises that “the cause of this sulkiness and dissatisfaction should be inquired into and removed, or they are apt to run away or fall into the negro consumption.” However, if slaves were “sulky and dissatisfied without cause,” he states that the treatment was “in favor of whipping them out of it, as a preventive measure against absconding, or other bad conduct. It was called whipping the devil out of them.”[2. Wikipedia also comments that another treatment for drapetomania included “removal of both big toes”, which makes running difficult.]

Chris becomes understandably “sulky and dissatisfied” with his time at the Armitage home and seeks to flee. Though he wasn’t whipped to treat his drapetomania, it’s not a hard stretch to argue that the plan to remove most of his brain (“coagula”) is essentially whipping the devil out of him so that only his body remains.

Dr. Cartwright apparently published these ideas in the New Orleans Medical and Surgical Journal (as well as De Bow’s Review, a magazine of “agricultural, commercial, and industrial progress and resource” in the American South). This publication came from his work as the chairman Louisiana State Medical Convention committee. One of their tasks was to “examine the diseases peculiar to the Black slaves of the antebellum South”.[3. From a Lancet article called “Drapetomania“.] This was a professional medical opinion!

To be clear, not all physicians agreed with Dr. Cartwright’s opinion. Dr. Hunt, a physician who practiced in Buffalo, New York—that is, North of the Mason-Dixon line—lampooned Dr. Cartwright’s concept of drapetomania. He rightly wondered why drapetomania seemed to only exist in the South. He made wry remarks that drapetomania seems to affect the neurons of slaves so that they only flee in a northerly direction. He also pointed out that drapetomania resembled the condition of schoolchildren who ran away from school to play.

In essence, Dr. Hunt shouted, “Context matters!”

Dr. Cartwright sincerely believed that drapetomania was an inherent quality of black people.[4. Dr. Cartwright also described “dysaethesia aethiopica“, or “hebetude or mind and obtuse sensibility of body” that only occurred in blacks in the South.] As he was a fish in the sea of Southern slaveowning culture, he either could or would not believe that social and political context affects the definitions of psychiatric conditions. (He also could not believe that his ideas were wrong.) Maybe Jordan Peele was thinking about Dr. Cartwright and drapetomania when he created the characters in Get Out. Maybe he wasn’t; maybe he was pointing out the consequences and longevity of racism.

Psychiatry has been and can easily become an agent of social control. The moment we begin to think that we’re too good or too smart or too sophisticated to become agents of social control, we and the people under our care are doomed.

It is paramount that we remember this always in the current political climate. May we have the wisdom and courage of Dr. Hunt.