Category: Lessons

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Consult-Liaison Education Informal-curriculum Lessons Medicine Reflection

What is the Question?

I can think of only two times in my life where I received formal instruction on how to ask questions.[1. Without a doubt there have been more than two occasions when someone taught me how to ask questions, but it appears that I either was not paying attention or the lesson was not memorable.]

The first instance was when my parents taught me how to order food in a restaurant. They told me to make a single choice and have my order ready before the wait staff appeared. (“Don’t waste their time.”) They told me to phrase my order in the form of a question:

RIGHT: “Can I have the grilled cheese sandwich, please?”

WRONG: “I want the grilled cheese sandwich.”

My parents also told me to look at the faces of the wait staff and to speak loud enough so they could hear me. They also told me to thank them after they took my order.

(When I became more finicky about sentence construction, I changed the beginning of my orders to “May I…?”. This is mostly due to my 6th grade English teacher who, in his booming voice, would challenge any student who said, “Can I…?” “I don’t know, CAN you? CAN you go to the bathroom? If you CANNOT, perhaps you should see a DOCTOR. MAY you go to the bathroom? Yes, you MAY.”)

In sum, I was supposed to know what I wanted and exercise good manners.

The second time I received formal instruction on how to ask questions was during my third year of medical school.[2. Of course I received formal instruction on how to ask questions throughout my training as a medical student and as a psychiatry resident. However, that was over the course of years and done with varying quality. There were also all the people who taught me how to ask questions and I didn’t understand at the time that they were teaching me how to do that. Communication is difficult. This also explains why my efforts to ask boys out on dates in my youth often resulted in said boys looking at me askance and running away.] Interns and residents often asked medical students (e.g., me) to call consults.

Here’s the thing: When you’re a medical student, you don’t know how to do things like call consults because you don’t entirely know what you’re doing. Mastery comes with practice. Mastery also results from direct feedback, which often comes from exasperated and impatient residents.

When you call a consult you’re asking another service to help you with your patient. For example, if I’m a surgeon and I have a patient who stabbed himself multiple times in the abdomen in an attempt to kill himself, I’ll do the surgery to look around inside and make sure there aren’t injuries to internal organs. However, as a surgeon, I don’t know what to do about my patient’s urges to stab himself, so I’m going to call the psychiatrist to ask her for help.

WHAT IS THE QUESTION?

A surgical intern named Tom[3. Tom had cropped blonde hair. He wore leather pants sometimes. He often went dancing when he wasn’t working. He was smart and, perhaps more importantly, he was kind.] taught me how to call a consult while we were speeding around the hospital one day.

“Before you call a consult, you have to know what you want. What is the question you want answered? The patient is your patient, so you have to provide most of the care. But if you need help, what do you need help with? Don’t just say that the patient has diabetes and high blood pressure. That’s not a question and it’s not clear what you want. Make your question very clear:

‘My patient has diabetes and high blood pressure. He took insulin regularly before he came to the hospital, but now his blood sugars are high. They haven’t been below 300 since he’s been here. Can you help us bring his blood sugars back down?’

See how that’s a clear question? If you ask a clear question, you’ll get answers that will actually help you.

And be nice. Some of the residents you talk to won’t be nice, but that’s just because they’re tired and stressed out. Don’t take it personally.”

In sum, I was supposed to know what I wanted and exercise good manners.

To be clear, it’s not like I had this one conversation with Tom and I thereafter called in stellar consults. I still went on for too long and didn’t share pertinent pieces of information. Residents interrupted me before I had spoken for five seconds and they often made no effort to mask their annoyance.

But! It set me on the path of continually clarifying for myself what I wanted and how to craft better questions. Focusing on “WHAT IS THE QUESTION” has helped me as a psychiatrist (much of the work is often helping other people clarify for themselves what they want), a teacher (if people don’t understand something and get stuck, it’s often because they don’t know what they want to know), and as a human being (when meeting someone new, the question might be as simple as, “How can I make this person feel comfortable so maybe we can become friends?”).

Sometimes asking questions is more complicated than just knowing what you want and exercising good manners (e.g., “Will you marry me?”). Doing both, though, is an excellent place to start.

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Lessons Medicine Reflection Systems

Reflections on Psychiatry.

A medical student named Anthony sent me an e-mail and asked:

Are [the items listed below] things that have nagged at you during your training or as a psychiatrist now? How do you deal with the ambiguity of psychiatry, or do you find that as your clinical experience grows, you find yourself more reassured in what you do from seeing your patients improve? Where do you see psychiatry going in the next couple of decades? I understand these are big questions, but I feel it would be incredibly helpful to hear from someone who’s been practicing for a while.

Indeed, these are big questions, but the big questions make us reflect on what we do: What is the point? Why do we bother? Are we doing the “right” thing?

Are these things that have nagged at you during your training or as a psychiatrist now?

The things Anthony listed as frustrations—the primacy of the biological model, the lack of novel and consistently effective medications, the role of medications and pharmaceutical companies, the medicalization of “normal” human experience—resonate with me, too. These things bothered me while I was in medical school, irritated me when I was a resident, and continue to vex me as an attending.

What bothers me the most is how psychiatry can become an agent of social control. Psychiatry can lend its vocabulary and constructs to authorities to oppress or exclude certain populations.

Consider the spate of school shootings. If we label the shooters as “mentally ill”, that distracts from the culture of fear and violence. Homosexuality was a legitimate psychiatric diagnosis until 1973. African Americans are more likely to receive diagnoses of schizophrenia.

Words are powerful. The ramifications of diagnosis are serious. We must not forget how our words can affect how people perceive themselves and how others treat them.

This overlaps with the medicalization of human experience. Is it okay that people receive Xanax from physicians when they are grieving the death of a loved one? Is it okay that students receive Adderall from physicians when they are striving for academic excellence? Is it okay that people from other cultures receive antipsychotic medication from physicians when they report hearing the voices of their ancestors?

My discomfort with this has affected my practice: I purposely choose to work with people who exhibit symptoms that rarely overlap with the general spectrum of human experience. Most people do not believe that someone has stolen their internal organs. Most people do not drink a fifth of alcohol each day to cope with guilt and shame. Most people do not fear that aliens will execute them if they move into housing from the streets.

A natural consequence of working with this population is that advocacy becomes a large part of the work: People with severe conditions can and do get better. Most people enter medicine to help people, to see people get better. The gains in this population may take longer and sometimes may not be as great as in other populations, but they do occur.

How do you deal with the ambiguity of psychiatry, or do you find that as your clinical experience grows, you find yourself more reassured in what you do from seeing your patients improve?

I learned early on that, if I don’t know the answer, the best thing to do is to say, “I don’t know.” It can be hard to say that out loud because we don’t want to admit our ignorance to ourselves or to others. Perhaps the difficulty isn’t the ambiguity of psychiatry. Maybe the challenge is managing our own vulnerability.

This is how I deal with the ambiguity:

  • I remind myself that it is impossible for me—or for anyone—to know everything. That doesn’t mean I give up and walk away: I do the work to learn as much as I can. The learning never stops, even when I want it to.
  • I remind myself that I will mess up. I hope that I will make fewer mistakes as I advance in my career, but I trust that I will screw up. I also hope that I will have the wisdom and humility to learn from my errors and avoid them in the future.
  • I remind myself to “First, do no harm.” I may feel pressure[1. Know that the system will often put pressure on you to “do something”. That doesn’t mean the system is right. Unless someone is dying in that moment, there is always time to stop and think.] to “do” something—prescribe a medication! send someone to the hospital! intervene right now! There is always time to pause and consider: “Will this cause (more) harm?” To be clear, I don’t advocate living life through avoidance. Sometimes the way to navigate ambiguity is to avoid actions that will make things worse.

I’m sure this isn’t the first time you have heard an attending say this: The farther along I go the more I realize how little I know. There is so much more for me to learn.

Where do you see psychiatry going in the next couple of decades?

Experts are much better at describing base rates than they are at predicting the future.[2. This idea about base rates and predictions comes from the book Decisive, which I recommend with enthusiasm.] This is an important question that deserves more reflection. Different ideas spin in my head: Psychiatry will have to reconcile with people who have experienced mistreatment from our field. Psychiatry must examine social determinants of health and scrutinize how they affect diagnosis and treatment. Psychiatry must collaborate with other fields and cannot expect that isolation will actually help patients, our colleagues, or the specialty.

For you (and me) I would add that we cannot expect to influence or change a system if we do not take part in it.[3. Full disclosure: I am not a member of the American Psychiatric Association. My values do not seem to align with theirs. However, who am I to complain about the values of the APA if I’m not willing to help shift them? And how can I contribute to any shift if I do not join them?]

Good questions, Anthony. I encourage you to ask other psychiatrists these same questions. Regardless of which field you choose to enter, I hope you continue to exercise curiosity and healthy skepticism of the work you do. This will not only help you grow as a person and physician, but will also help your patients and field of expertise.

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Lessons Observations Reflection

Truths from Glacier National Park.

This is St. Mary Lake from Glacier National Park in Montana:

WGI

My time in the great outdoors reminded me of these truths that I often forget:

The world is much bigger than any of us. Those mountains have existed for much longer than we have and will continue to do so long after we are gone. While it is true that even mountains will one day disintegrate (… and glaciers will melt and inland seas will evaporate…), they will persist much longer than any of us.

What a way to put our problems and worries into perspective!

When we die (a detail we all neglect to remember), none of this stuff will matter. We shouldn’t get too attached to what we do or what the outcomes are. Those mountains, glaciers, lakes, and forests were doing their thing long before we were born… and they will continue to do so after we die. We are lucky to be here to experience all this stuff, but, in the grand scheme of the universe, we are mere blips in time.

Life is ephemeral, so appreciate The Moments while you can. We’re those people who are out on the trails before 7am. The morning light only shines for a few minutes, so you must appreciate the soft glow it casts across the sky, mountains, and valleys when it happens. You also know that you can’t stay on top of the mountain and look at the spectacular vista forever. And you realize—maybe with some sadness—that the camera cannot capture the colors, textures, width, and energy of the scene.

So you appreciate it for what it is… and then you let go of it because you must. There’s a lesson in there about gratitude and grace.

People take care of things. People who venture into the great outdoors are all there for the same reason: We want to see the grandeur and beauty of nature. And these people come from all over: They have different hair, eye, and skin colors.[1. To be clear, though, the vast majority of people we saw while hiking were white people. This is not a new observation. While no one at Glacier asked me if I can speak English, people at other national parks have. White People Love Hiking. Minorities Don’t. Here’s Why.] They speak in different accents, languages, and dialects. They dress in different styles and carry different accoutrements. They nonetheless make eye contact and greet you. They warn you about potentially dangerous wildlife up ahead. They take care of things for you: They don’t pick the wildflowers so you can see them. They pick up their trash so you don’t have to. They stay on the trail to prevent further erosion of the earth.

People can do ugly and violent things. People can also do beautiful and kind things, and not just in national parks.

The world is a beautiful place. Much of the world’s beauty arises from imperfection. Mountains are jagged, lakes are non-uniform shades of blue, glaciers have irregular borders and rough surfaces, trees are bent and twisted in strange ways, boulders are shattered into coarse rocks, and clouds have different textures as they stretch across the sky.

Nature is non-uniform, random, and imperfect—and therein lies its grandeur. Is it the same with us? In society we want “perfection”, whatever that is, but the very nature that we find so beautiful and breathtaking is all imperfect.

May you soon have the opportunity to remember those truths that you know you forget.

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Education Lessons Medicine Nonfiction Reflection

We Want to See Them Better.

When he and I first met he told me that he had a doctoral degree in psychology, was the CEO of the jail, and could speak 13 languages. To demonstrate, he said, “Hong tong ching chong lai tai!” He then punched the door to his cell and shouted, “GET THE F-CK OUT OF HERE, B-TCH!”

I did.

The next week, he answered my questions about the pencil drawings on his walls.

“My name is John Doe,” he said, the words spilling out of his mouth. “You all think my name is Peter Pan, but it’s not. It’s John Doe. See my name up there?” He pointed at the “John Doe” he had written in two-foot high letters on his cell wall. “That’s my name. My people call me John Doe. I am the leader of all the people. I am the leader of all the Asians. I am half-Asian.”

Nothing about him looked Asian.

More weekly visits occurred.

“I can speak 13 languages,” he said again. “Tingee tongee tai tai—;”

“You’re making fun of me,” I interrupted.

“I’m not,” he said, smiling. I’d never seen him smile before.

“No, I’m pretty sure you are.”

“I’m not. Aichee aichee—”

I walked away.

“Hey! I’m a doctor! I own the jail! I CONTROL ALL OF THIS!” he shouted at me.

I kept walking.

One week I was trying to speak to a man in a nearby cell. John Doe was shouting: “The police are pigs! They don’t know anything! I hired all of them! I own them!” His vitriol bounced off of the concrete surfaces of the cell block; I couldn’t hear anything but his reverberating voice.

“Excuse me,” I said to the man. John Doe was still shouting when I arrived at his cell door. He fell silent.

“Could you please not yell for ten minutes so I can talk to another guy here?”

He nodded.

“Thank you,” I said, returning to the man.

Two minutes later, John Doe started yelling again. I sighed.

“That John Doe—he really pushes my buttons. I don’t know what it is about him—people have said and done much worse things, but there’s something about him….” I said in exasperation to my colleagues. “I mean, I know he’s ill, but…!”

He declined to take medications. He followed his own prescriptions of daily showers, three meals with extra fruit if he could get it, and daily bodyweight exercises. He rarely slept.

Another week the same situation occurred again: I wanted to talk to another man in the same cell block as John Doe, who was shouting.

John Doe stopped yelling when he saw me approach his cell.

“Could you please not shout for ten or fifteen minutes so I can talk to another man here?” I asked, resisting the urge to shout at him.

He nodded. I didn’t say “thank you” this time.

I completed my interview with the other man. John Doe remained silent the entire time. I was surprised.

“Thank you for not yelling. I appreciate it,” I said to John Doe on my way out. He nodded.

As I walked out of the cell block, I heard him shouting again.

More weekly visits occurred. John Doe still declined to take medications. He stopped speaking to me in faux-Asian languages, though would occasionally speak in gibberish that I did not understand. He stopped shouting whenever he noticed that I had entered the cell block.

“You’re not a real doctor,” he said one day. “You must be a nurse.”

“What makes you think that?”

“You’re a woman. Women aren’t doctors. Maybe you’re a clinic assistant. A really smart clinic assistant. But you’re not a doctor. Women can’t be doctors. I’m the president of all the doctors and hospitals. I own all the hospitals and jails—”

“Okay. Is there anything I can help you with today?”

A few weeks later, John Doe was no longer in jail. A judge declared that he wasn’t competent to stand trial due to his psychiatric symptoms. He went to the state hospital to receive treatment.

More weeks passed. He eventually returned to jail once his competency was restored, but he didn’t return to psychiatric housing. My colleagues who evaluated him upon his return, however, shared news about John Doe with enthusiasm.

“He’s taking meds now and he’s better. He’s polite. He answers questions. He doesn’t talk in fake languages. He doesn’t shout. I mean, he’s not warm or friendly and he doesn’t talk much, but he can hold a conversation. He’s definitely better.”

“What?” I exclaimed. “Are you serious?”

I wanted to see him. I wanted to see him better.

Despite that, I never did: He would not have found my visit therapeutic or helpful. The only person who would have felt better after that visit was me.

One of the greatest rewards in health care is helping and seeing people get better. This is particularly true when people have severe illnesses. We want to see them better. It gives us hope that other people who have comparable symptoms—symptoms that scare us, worry us, sadden us—will get better, too.

“How will [action x] change your management?” That’s a question we often talk about. If that lab study won’t change what you do, don’t order the lab. If the patient’s answer to your question won’t change how you proceed, don’t ask the question.

John Doe was no longer my patient. He was better. I didn’t need to see him to believe it.

Categories
Education Lessons Medicine

Negotiating a Job Offer (IV).

Negotiating a job offer can make us all feel uncomfortable because the noise in our head stops us from asking for what we want (and often deserve). Ladies, this post is for you because, even as physicians, we still earn less money than our male colleagues[1. From the White House: In 2014, Women Continue to Earn Less Than Men. From Forbes: Even Women Doctors Can’t Escape The Pay Gap.] and we often do not assert ourselves as much as we could during negotiations. That doesn’t help us as individuals or as a population.

One of the most important things to keep in mind during negotiations is that you’re not asking for “too much”. You are going to work hard for your employer. You want to arrange the details of your job so that you can create your best work with as few obstacles as possible.

As a resident, we had to pay for parking on nights when we were on call. We all hated that. Why do we have to pay for parking when we’re in the hospital working all day, then all night, and then for most of the next day? If we could have negotiated our jobs so that parking was covered when we were on call, then we would have felt less resentment about our roles. This is an example of a psychological obstacle that could get in the way of doing your best work.

First, consider that it is your employer’s job to say “no” to any negotiation request you make. That doesn’t mean that s/he will say no. If you assume that it is your employer’s job to say “no”, though, it’ll make negotiations feel less personal. (This is an example of a mental shift that is meant to help you, even if it is inaccurate. Sometimes cognitive distortions are helpful.) This mindset will also help you assess your priorities during the negotiations: What matters most to you, where you won’t take “no” for an answer? What is less important, but would be nice to have?

Second, consider it your job to ask for everything you want. By asking for everything you want, you demonstrate multiple things to the organization:

  1. You have the confidence to ask what you want.
  2. You show your strong communication skills in asking for what you want.
  3. You have the skills to advocate for yourself.
  4. You can use those same skills to advocate for your patients, your colleagues, the organization, and other parties.

On a practical level, naming everything you want also provides room for compromise. Your inner critic may balk at the idea of asking for everything you want (“I’m asking for too much!”). Organizations use your inner critic to their advantage because they know it is difficult for potential employees to ask for what they want. However, organizations need employees and, if they’ve already offered you a job, it shows that they specifically want you.

Know your style when it comes to negotiations. Some people aren’t “phone people”. Some people prefer conducting negotiations over e-mail, where one can take time to mull over options before responding. Some people prefer having conversations in person. This last preference has an advantage over the other two: It is hard to say “no” to someone’s face. Negotiating in person also sends a meta-message that you can manage potentially uncomfortable conversations with skill.

Lastly, remember that potential employers should be on their best behavior during interviews and negotiations. If they aren’t treating you with respect when they ought to be courting you, how will they treat you once you are formally working for them? All of these interactions provide information: Do you want to work for someone who isn’t putting forth a best effort to impress you? You’re likely working hard to make a good impression on them, right?

I hope the posts in this series will help you have more confidence and skills as you seek work. People often talk about “self care”, a concept that can sound hollow and corny. May these concrete suggestions help you in the realm of self care, as crafting a job that brings you satisfaction will help you take better care of your patients. Good luck.