Category: Lessons

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Lessons Nonfiction Observations Reflection

On Knowing Yourself.

I know of only two people who, upon starting medical school, knew that they wanted to become psychiatrists. (How did they know what they wanted to do eight years before they did it???) They both achieved their professional goals: One created a community clinic for people with severe psychiatric illnesses. The other became an addiction psychiatrist and now oversees an entire substance use disorder program for a health care organization.

I was not one of those people. As a youth, I aimed for family medicine, a generalist that would help people of all ages. While studying microbiology in college, I aimed for infectious diseases: The ingenuity of single-cell organisms! The science behind antibiotics and antiretroviral medications! The elegance of diagnosis and treatment! (My fascination with microbiology persists.) In medical school, I learned that infectious disease is a subspecialty of internal medicine and, WOW, there are a lot of subspecialities within internal medicine! Oncology (cancer) and nephrology (kidneys) captured my attention for a while—more incredible physiology that occurs on a cellular level!—and, then, seemingly out of nowhere, appeared psychiatry.

We’re biased when we look back at how things unfolded: We can’t change the past, so we tell ourselves that it all worked out the way it was supposed to. So, yes, of course I was supposed to go into psychiatry all along.

It became clear during my psychiatric training that I prefer to work with people who are experiencing severe psychiatric symptoms, particularly psychosis (e.g., people who hear voices saying terrible things about them, people who believe that someone has exchanged their internal organs for someone else’s). I also like the intersection and interplay of physical and mental conditions: Sometimes people who have significant medical illness develop striking psychiatric symptoms, which resolve along with their medical illnesses. Sometimes people with significant psychiatric illnesses develop significant medical problems, and successful treatment of both conditions requires teamwork. Complex problems are fascinating. Witnessing people recover from complicated conditions is rewarding. I’m lucky that I have had the opportunities to do this work.

I’ve also recognized that I am not consistently warm and empathic to people who are experiencing mild psychiatric symptoms. Two previous patients come to mind:

  • “I’m so stressed out,” she said while wringing her hands. She began to pick at the tassel of her Coach bag. “I don’t know which to remodel first: The beach house? the pied-a-terre? or the kitchen in our home? It’s all I think about and I’m starting to lose sleep over this.”
  • “My girlfriend started taking Prozac a few months ago, and it seemed to really help her. She has a lot more creativity. I’m thinking it might help me with that, too. In my line of work, creativity is important and if Prozac will help me with that, I won’t feel as much pressure on the job.”

For the woman with the three properties, we worked through that with minimal use of medications. I’m not proud to say that, for the man who desired creativity, I stared at him blankly when he was done speaking.

It’s important to know yourself. As I understand it, it usually takes at least a lifetime to learn about yourself. Even then, most people never know themselves completely by the time they die.

Learning about yourself helps you recognize how you could do things better or differently. We all have our weaknesses. They exist, even if we wish they didn’t. Everyone else sees them, even though we don’t.

There are many ways to get glimpses of our blind spots. If we’re willing to linger a bit when we catch these glimpses, we have the opportunity to make ourselves more awesome.

However, it’s hard to linger because these glimpses often occur when we’re angry or annoyed. Maybe you make an executive decision for something to happen and a lot of people don’t like it. Maybe you learn that not as many people liked or supported you when you thought they did. Maybe you wish that an institution or a group of people would write or say nice things about you, but they don’t.

How it burns!

These are all opportunities to get to know yourself a little better:

  • What emotion am I experiencing?
  • What happened that led me to feel this way?
  • What do I think the truth is?
  • Is it possible that what I think is true isn’t actually true?
  • What questions could I ask to learn more?
  • What do I think might happen if I start to ask questions?
  • What would it mean to show ignorance?
  • What would it mean if I were wrong?

Wherever you go, you bring yourself with you. Even if you do not yet have any interest in learning about youself, that doesn’t stop other people from learning about you. It is much more humiliating when everyone else knows you much better than you know yourself.

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Lessons Medicine Reflection

On the Importance of Hobbies.

During medical school, professors advised us to “have hobbies” and to “do stuff outside of medicine”:

  • “It’ll give you have something to talk about with patients.”
  • “It’ll help you maintain balance as you go through your training.”
  • “It’s important for self-care.”

Medical students, as a population, tend to be compulsive and there’s always more to read and learn. (Medicine, like many fields, entails lifelong learning, even when you are tired of lifelong learning.) It’s easy to drop other activities and study all the time.

As I’ve aged, my understanding of their advice has changed.[1. Even before I chose to enter the field of psychiatry, I was skeptical of the reason that hobbies “will give you something to talk about with patients”. While I believe that physicians should present as human beings at work, patients also don’t visit doctors to talk about shared hobbies. There are plenty of other shared topics to talk about, such as the weather, regional sports, etc. As physicians have limited time with patients, it seems self-indulgent to talk about MY hobbies when my role is to help the patient. Some may argue that my stance results in too rigid of a boundary, though I don’t think patients want to learn about our hobbies during medical visits. That’s what social media is for, right?]

When I’m not at work, no one calls me “Doctor”. I have hobbies, sure, but not solely to provide balance to my work in medicine. Working as a physician is an important part of my identity, but it’s not my entire identity.

And that’s where the value of hobbies come in. Physicians spend a lot of time in school and at work. Our jobs can easily become our entire identities. So if we have a bad day at work—maybe because we saw more people than usual with severe illnesses; maybe because we learned that one of our patients died; maybe because we’re frustrated with all the things we have to do that seem unrelated to actually taking care of people—we can feel terrible if that’s the sole lens in which we view our lives.

If I view myself only as a physician, then a crappy day at work means I will be in a foul mood for the rest of the day. And the only thing that will change that is a “better” day at work.

The importance of having hobbies is to experience growth and success outside of medicine. Maybe a patient said terrible things to me today, but I made a delicious soup from scratch. Maybe one of my patients died, but I was able to write about the loss in a meaningful way. Maybe the system isn’t broken; maybe it was built this way… but I finished a half marathon without stopping to walk.

Similarly, maybe my coconut-and-vegetable rice dish didn’t come out quite right, but one of my patients who has been psychotic is getting better. Maybe my hamstring is strained from running long distances, but I was able to help a nurse practitioner improve his clinical skills. Maybe blog posts I am proud of don’t seem to impress anyone else, but I was able to help nudge a policy to help improve patient care for a particular population.

Those are binary pairings, but it works across multiple spheres. I finished a book about a murder AND one of my patients isn’t getting better AND that new soup recipe turned out better than I thought it would. Life has its successes and failures. If we’re able to look back on the day and the sum of events is greater than zero, we are lucky.

So, for any medical students who are reading this, yes, make an effort to cultivate hobbies. Yes, hobbies make you a well-rounded person. More importantly, though, when you practice cultivating your hobbies now, you’ll be better at both the cultivating and the hobbies themselves when you’re a resident and an attending. You will have terrible days while you’re in training and when you’re working. You have a front seat in the theatre of human drama. These other hobbies will help you remember that you are a multifaceted person, that you are not your job.

And while you may take pride in being a physician, the reality is that you will not practice as a physician forever. You will one day retire from the practice of medicine. And, indeed, this will all end one day and you will die. While people may remember you in your role as a physician, people may remember you even more for your talents in cooking, your boundless knowledge about sports, the curious pieces of art your crafted, and your perspectives as a person who happened to work as a physician.

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Consult-Liaison Education Lessons Nonfiction Reflection

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

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

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

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

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

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

Have compassion on the kid.

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

Have compassion on the elder.

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

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

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

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

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

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

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Lessons Nonfiction Reflection

Racial Slurs and Hurt Feelings.

You could feel the air rushing out of her lungs and into your face if she was screaming at you.

“STOP CALLING ME A WHORE! I AM NOT A WHORE, YOU DIRTY N-GGER!”

No one, in fact, was calling her a whore.

“DON’T LIE TO ME, MOTHERF-CKER! I HEAR ALL OF YOU CALLING ME A WHORE! I HEARD IT, JUST NOW!”

Her best defense was a loud offense that included liberal use of racial and homophobic slurs. We winced and asked her to stop when the colorful epithets flew from her mouth. She glared at us, her face red and fists clenched.

Despite seeing her multiple times over the course of two years, she, up to that point, had never made any comments about my race. (I look obviously Asian.) Then, one day, with an audience of a dozen people:

“YOU CAN F-CKING GO TO HELL, DR. YANG, YOU F-CKING CHINK!”

As she stormed out of the building, I grinned and put my arms up in the air in victory.

It’s about time!

Some people immediately expressed their concerns (“I’m sorry she said that”; “Are you okay?”), the distress apparent on their faces.

“It’s okay,” I replied. “I consider it a badge of honor.”

“Yeah, but that still must hurt.”

I shrugged. I felt amused, not hurt. I didn’t need them to take care of me.

They, of course, had good intentions. There was just so much they didn’t know:

That one time when my parents and I were biking along a dry river bed. I was eight years old. Two young men, both white, began trailing us. They began to shout things at us that I didn’t understand. They didn’t seem friendly.

“Stay between your mom and me,” my dad instructed in Chinese.

“Don’t say anything back to them,” my mom added.

For the next half hour, they continued to follow us. They continued to shout things at us. They often laughed.

They followed us to the parking lot and continued to shout things at us as my parents loaded the bikes into the van. As my dad drove away, they threw something at the car.

That one time I was pleading again with my mother to leave the Girl Scout troop. I was nine years old.

“I don’t want to go anymore!” I said in English.

“No, you have to go. It’s a good activity and you learn how to get along with others,” she replied in Chinese.

“But I don’t fit in. I just don’t fit in!” in English.

“Of course you fit in. You go to school with the other girls, you know all of them, they’re all good kids—” in Chinese.

“That doesn’t matter. I don’t look like them, I don’t act like them, we don’t do the same things. I don’t like it. I don’t fit in!” in English.

Silence.

“You don’t fit in,” my mother said in her thickly accented English. There were at least ten girls in the troop. I was the only person of color. Her face was no longer stern.

“Okay,” she said. It’s a word that is used in both English and Chinese.

That one time when my parents and I were walking through a parking garage. It was a hot day and a convertible with its top down approached us. The group of white guys in the car shouted “KONNICHIWA!!!” at us; we could hear them laughing as they roared past.

“WE’RE NOT JAPANESE!” I shouted back. I was ten years old. My parents shushed me.

That one time when I used my fingers to briefly transform the Asian monolids of my eyes into something that resembled double eyelids.

That one time became multiple times over the course of several months. One day, I didn’t have to manipulate my eyelids anymore: My double eyelids remained stable. My eyelids sort of (but only sort of) looked like the eyelids of the girls in Teen Magazine.

I was twelve years old.

We all have ways in which we don’t fit in, in which we’re different. We all have also learned how to take care of ourselves when others antagonize us for being different. We wouldn’t be who we are today—for better or for worse—if we didn’t have those unpleasant experiences.

No, it didn’t hurt when she said the slur. Other things have hurt much more.

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Lessons Medicine Nonfiction Reflection

Repost: Control.

I wrote the post below over ten years ago during my last year of medical school. I was on an elective hospice rotation. This came to mind this weekend after I visited a mentor who is dying from cancer. Someone from a hospice service also visited him while I was there.

I will miss him.

We all die.

Really. We all die.

And people know this. Sort of. Kind of. Maybe.

Some people accept this fact that yes, we all die, with calm grace. Some, indeed, genuinely welcome death and look forward to shedding this mortal coil. Some don’t necessarily want to die, but they recognize the inevitable fact and actively choose to spend the rest of their days living, not dying.

And then there are people who fight death. Or maybe it’s not death itself that they fight; they fight their mortality. They struggle with the fact that life will end. They don’t want to relinquish control over their existences. They want to know how much time they have left, what exactly will happen, and how things will progress between this moment and that last breath.

Family members of dying people (but really, aren’t we all dying?) seem to feel more—sadness? anger? frustration?—whatever; they often seem to feel more than the patients. The Type A’s get super Type A, jumping all over the place, asking How? When? Why? What? How much? How often? How quickly? How slowly? Can I do this? What about this? And that? The angry people get angrier, but I don’t think the core emotion is anger. The sad people try not to feel more sad, but their cheery smiles are obviously superficial. And the crazy people just get crazier.[1. I wince at what words I used to describe people in the past. I hope the wincing means that I’ve gained some wisdom over the years.]

It’s not fair to say that this grief is entirely selfish, but in a way, it is: If the loved one dies, it is a theft from the person in question. There will no longer be any shared moments, quiet glances, bursts of laughter, or shouting matches. And if the loved one dies, it only reminds us of our own mortality.

Because we all die. We just don’t believe it.

A hospice nurse and I sat in a family’s house for nearly an hour this afternoon. The patient, an aging woman, lay on the gurney in the living room. She’s had multiple strokes and doesn’t interact with the world. Her eyes fix upon yours, but she’s not looking at you. Her pale lips, smeared with Vaseline, are parted. Her left foot writhes in the bed, as if forming cursive letters on the white sheets. Her skin is cool and she doesn’t really react to the touch of another human hand.

Her daughters keep extensive notes about her: How much did she pee? poop? sleep? Has her skin changed color? Is she throwing up? How much morphine has she gotten? (They won”t say “morphine” in the room; they call it “M”.)

They don’t want to give her too much morphine because they fear that they will kill her. And yet they want her to be comfortable—and the grimaces on her face suggest that she is not. The daughter who is administering the morphine will not—cannot—give her any more.

“It’s about HER comfort, not YOURS,” her sister said, trying not to shout at her.

“Well, you don’t want to give it to her, so I am, and this is what I’m comfortable with,” the sister replied.

“I know she’s declining… I know she is…” and yet she cannot accept this fact completely and buries herself in her dying mother’s urine and fecal output, her blood pressure and pulse measurements, the dosages of her medicines.

It’s about control. Lack thereof, really. And to sit there, actively listen, and be present with these patients is exhausting. You literally feel what they feel, and yet you also feel what you feel in response to their feelings, and your brain is running through the algorithms of disease. So you monitor yourself while you monitor them, staying in the moment, completely unsure of how the next moment will unfold. Part of you wants to comfort them and part of you wants to scream in frustration. Part of you wants to run away and enjoy the gorgeous world outside and part of you wants to give everyone in the room a big hug. Part of you wants to give up completely and part of you wants to fight for the life that remains.

God, it is so beautiful to be alive.