Categories
Medicine Policy Public health psychiatry Systems

Reflections on Some Health Care Systems.

Items related to systems of health care that I learned and thought about this week:

National Medical Association. I am embarrassed to confess that, nearly 20 years after graduating from medical school, I learned only this week about the National Medical Association. This came about while I was learning some of the history of the American Medical Association (AMA). In short, the National Medical Association was created because the AMA would not admit Black physicians into the organization. (I have never been a member of the AMA. My reasons have been squishy; I never truly believed that the AMA represented me or my interests. That hasn’t stopped the AMA from sending me invitations in the mail to join! It seems that over 80% of physicians are not AMA members, so I’m certainly not alone.)

Alexander Graham Bell and Eugenics. This Journal of the American Medical Association (emphasis mine) editorial from 1908 reports:

The subject of the production of better men and women was brought before the American Breeders’ Association by Professor Alexander Graham Bell, the inventor of the telephone, who for many years has been interested in certain social questions, especially those relating to the condition of the deaf and the result on the next generation of the consanguinity of parents as regards the production of deaf and blind children.

No one ever brought this up when we learned that he invented the telephone.

It appears that Bell’s interest in “breeding” was his observation, though the collection of some statistics, that parents who are related to each other seem more likely to bear children who are deaf. Bell made “an appeal for the collection of statistics by trained men who are interested and who have the opportunity to secure the definite detailed information” related to “the production of better children”. The unnamed author(s) of the editorial go on:

We are securing survivals to a much greater degree than before, and now it becomes a duty to secure, so far as it is possible, the origin of members of the race who will be worthy of survival. After all, the most important problem in evolution is not so much the survival of the fittest as the origin of the fittest.

Over 100 years have passed and this ugly question of “breeding” persists.

The Chinese Exclusion Act. I’ve commented on this Act before (here and here), but here’s an opportunity to pile on the AMA even more. In 1901, the Journal of the American Medical Association published a “minor comment” about “The Exclusion of the Chinese“, which you can view in its entirety in the link above.

Reading this made me think of vile rhetoric that has revived during this Covid-19 pandemic. Recall recent references to “disregard of sanitation” due to “[maintainence] to the fullest extent their oriental habits and traditions”. The Chinese, they just won’t do as we do.

“That this is a Christian country and we regard them as heathen, should not make us altruistic to our harm.”

Do we hear echoes from 1901 in the US’s current Covid test requirement for travelers from China?

Prescriptive Authority for Psychologists. There is a House bill in the Washington State Legislature that will give prescriptive authority to psychologists. Five US states currently allow psychologists to prescribe medications.

While it is easy to stumble into a debate about whether this should happen or not, I think this is a distraction. This debate is a manifestation of failure in public health policy.

Instead of trying to increase the number of people who can perform a highly specialized task, why not increase the availability of community supports and services so people don’t need highly specialized treatment?

Consider the decrease in anxiety and depression that would result if people were confident they could pay their rent? feed their families? take time off to care for their newborn? secure an education or training–whether college or vocational school–that supports stable employment?

Think of the decrease in stress and trauma if people had better options than to sell drugs or sex? if neighborhoods had more green spaces and less air and noise pollution? if they had adequate and essential protections as “essential” workers?

Medical Mistrust and Meeting People Where They Are At. This paper about medical mistrust, racism, and health prevention describes an elegant way to recruit study participants: “collection of data [occurred] primarily in barbershops, venues with documented recent success in reducing blood pressure in African-American men”. It is elegant because it is simple, effective, and successful.

When I read this, I recalled a suggestion my father had around the time the Covid-19 vaccines were released. He lives near several Asian grocers, many of which are more like bodegas than grocery stores.

“Why don’t they set up vaccination stations outside these grocery stores? Everyone needs to eat. Elderly people go to these stores all the time. Laborers get snacks and cigarettes. Make it easy for people.”

Sometimes (often?) the best and most effective health care happens outside of medical spaces.

Categories
Informal-curriculum Medicine Reading Systems

Recent Readings.

Stack of read newspapers.
Photo by brotiN biswaS

On medicine being agents of social control. These three news articles highlight the misuse of authority within the context of medicine:

Delta ‘weaponized’ mental health rules against a pilot. She fought back. In short, a woman named Karlene Petitt was (and remains) a pilot for Delta airlines. In response to a general exhortation from Delta leadership to speak up about safety issues, she submitted reports that did just that. In return, Delta leadership sought to silence her and initiated a process to deem her “too mentally unstable” to be a pilot. Delta recruited a psychiatrist who provided a diagnosis to support this argument. (The psychiatrist apparently diagnosed her with bipolar disorder because of her many accomplishments—“well beyond what any woman [he’s] ever met could do”.) She contested this and took legal action. She won.

How a Chinese Doctor Who Warned of Covid-19 Spent His Final Days. This 16-minute video investigation includes remarks from a physician who provided care to Dr. Li Wenliang, the ophthalmologist in China who tried to alert the public about Covid-19 before he died from the infection himself. Around minute 11 of the video, both the narrator and the physician comment that hospital administrators wanted the health care team to provide an intervention (ECMO) that was not clinically indicated. However, it would buy the hospital administrators time and allow the hospital to report that the health care team “did everything”. The physician states that using ECMO would have been both a violation of medical care and medical ethics. This is an example of “reputation management” superseding clinical judgment.

Woman’s legal quest illuminates the rights of hospital patients who want to leave. Here, a woman voluntarily agreed to enter a psychiatric hospital for care, but was not permitted to leave upon request. Available documentation suggests that she was not at risk of harming herself or others at the time of her request to leave. Under these circumstances, that means the hospital was essentially holding her captive. (This is reminiscent of “On Being Sane in Insane Places“, where context affects how we evaluate situations.) Even worse:

“All patients admitted to the facility,” the manager said, meet the criteria to be involuntarily committed, “even voluntarily admitted patients.”

The manager told DOH investigators that staff “do not orally notify voluntary patients” of their right to be released immediately, despite a state law requiring this disclosure. If they did, he said, “Everybody would be asking to leave.”

Those two short paragraphs reflect poorly on the hospital in question.

On the death penalty. The first two articles present opposing perspectives on the death penalty. The third article provides a first-person account of being in prison, which adds context to the first two articles.

If Not the Parkland Shooter, Who Is the Death Penalty For? Here, the author describes justifications for punishment:

Society embraces four major justifications for punishment: deterrence, rehabilitation, incapacitation and retribution.

I’ve not seen it described this way and appreciate the framework. This might be a red herring: The author also argues that the Parkland shooter’s “human dignity requires his just punishment [with the death penalty] as an end in itself”. I struggled to wrap my head around this one: We usually cite people’s humanity and dignity as reasons to keep them alive, not to kill them.

I Wish the Jury Had Not Sentenced My Family’s Killer to Death. In contrast, the author here argues how the death penalty, while maybe just, doesn’t actually solve any problems. It instead only prolongs suffering for the families of victims. Also, “death by incarceration” is still death. (I also appreciated her firm recommendations about how to support people who experience unspeakable tragedies.) While the author of the previous pro-death penalty piece focuses more on theory and logic, the author here focuses more on practicalities and emotions. Both models have value. Both articles made me consider my own stance on the death penalty.

Prisoners Like Me Are Being Held Hostage to Price Hikes. The author of this piece is currently in prison. Though I have never worked in prison, I have worked in jail. His descriptions about commissaries, food items, and access to various items seem similar to what I have observed in jail settings. (It also continues to baffle me how businesses are allowed to make money off of people in jail—including medical care!!!) Nobody is spared from inflation and price hikes.

To end this on a lighter note: This artwork from Andy J. Pizza made me feel a variety of invisible things:

Categories
COVID-19 Medicine Nonfiction

Stairwell as Sanctuary.

Old, concrete stairwell with brightly-lit windows in the background.
Photo by Ryutaro Tsukata. This stairwell looks similar to the one I frequently used for myriad reasons while I was in residency training.

I wrote the following op-ed in late July, though never submitted it for publication: While I share an opinion, I don’t offer any solutions (and none have come to mind since then). Since President Biden has announced that the pandemic is over, now is the time to share this essay.


There is a stairwell or bathroom in every health care setting that has served as a sanctuary for medical professionals. We hold our breath and stifle our sobs while we stride towards the sanctuary; we wish to get there before anyone sees us weep. The tears fall because we learn a vulnerable patient died. A cherished colleague is leaving. A faceless health insurance reviewer has denied treatment. We run out of options to help someone because of choices an institution made. We wish we knew more, could do more.

As health care professionals, we are familiar with disappointment and sadness. Both are a part of our training and professional experience. We, however, are now experiencing enormous, unprecedented loss. Like ripples on a lake, our reactions to this loss will radiate forth and touch everyone in our communities.

The loss of life from the Covid pandemic looms over us. Over one million people in the United States have died from SARS-CoV2; we provided care to them in clinics, homeless shelters, jails, crisis centers, emergency departments, and hospitals. The individuals did not only die from Covid; others died from social consequences of the pandemic. Under- and untreated medical problems took away quality and quantity of life. Drinking, smoking, and injecting in doses too large offered relief from pain that defied description. Suicide seemed like the best choice among miserable options. We said their names and saw their faces, even as ours were covered with masks and goggles. Out of respect for patient privacy, we do not share these stories. In silence, we think of those who have died. This silence grows because we cannot find words to describe the shape, size, and saturation of our growing grief.

Even if we are able to share our sorrow, we have fewer colleagues around to listen. Diminishing clinical guidance, financial resources, and infrastructure support for health care professionals caused nearly 20% of us to either flee or flame out. (We understand why they left. We think about leaving, too.) Some retired early, others left for jobs that require less contact with distress and disease. They took with them their experience and expertise, which helped not only patients, but also us. Still others, recognizing already limited support dwindling further, took advantage of market forces and took jobs that were circumscribed in time and substantial in compensation. Health care delivery largely occurs in teams. When team members turn over frequently, the lack of team trust and cohesion often erodes the quality of care patients receive.

Earlier in the pandemic, we viewed the CDC as a part of our health care teams, as they have what many of us who work in safety net settings don’t have: Authority, public health expertise, and resources, including time to read and think. Over time, the CDC let us down: Instead of providing reliable and proactive leadership, it dithered. The CDC’s inaction forced individual agencies and clinicians to craft guidance. Why was a psychiatrist left to lead a public health response for a homelessness services agency? We wanted concrete guidance to keep people healthy and out of hospitals; we received a meager menu that deferred to the whims of politics and skeptics. We wanted tests and data to decrease disease spread and deaths; the CDC delayed sending out both laboratory and rapid tests. Recall that wealthy individuals and companies remained at home and procured tests with ease. Meanwhile, people labeled essential workers were treated as inessential: They could not access tests to protect themselves or their families. The CDC betrayed those of us who provide health care; we thus betrayed those who entrusted us with their health.

Health care workers must leave the stairwell or bathroom when our crying stops. Our tears may end, but the needs of patients do not. Physicians experiencing distress may be more prone to making medical errors. Fewer health care workers and disruptions of teams increases the work burden on those who remain, which increases their exhaustion and heartbreak. Without reliable guidance and leadership from a health authority like the CDC, we are unable to deliver unified, coherent health care. This will adversely impact not only the experiences of people who are ill, but will also result in population outcomes no one wants: More disease, more suffering, and more death. It may be too late to reverse this vicious cycle. We wish that we knew more, could do more.

Categories
Consult-Liaison Medicine

Coping Skills.

Grayscale photo of 11 tall clocks all reading the same time within a grove of trees.
Photo by Pixabay

I recently had a dental procedure that involved local anesthesia. I watched the dentist do her work through the reflection on the examination light. Though I didn’t see the drill, my entire head vibrated from my mouth. The gel she swabbed on my teeth was dark purple; for a few moments, it looked like she had removed them. The tip of the light that bonded the composite material first glowed a neon yellow, then flashed into nightlight blue. I left the office with a facial deformity and a speech impediment, though, thankfully, both disappeared as the anesthetic wore off.

(Science, technology, engineering, and mathematics are amazing.)

Dissociation is a useful coping skill at the dentist’s office. Though I was watching her work on the teeth in my mouth, the anesthetic left me feeling disjointed sensations: pressure and vibration, but no pain. Was this actually happening? My throat reflexively swallowed when the saliva began to pool; sometimes I tasted the metallic salinity of blood—my blood. But was this actually happening to me? My hands rested on my belly, like small boats of muscle, flesh, and bone floating on slow waves of abdominal breathing. A woman whose face I could not see was sanding down teeth. Were those actually my teeth?

When the dentist announced that she was done, I rejoined my body in space and time within one or two eyeblinks. Everything—except for the small, numb portion of my mouth—had reintegrated.

Problems arise when we only have one coping skill to deal with life’s myriad stressors. Imagine disconnecting from time during a job interview or separating from reality when a friend is in distress and needs your help. The interviewer may assume that you are inattentive or intoxicated. Your friend may come to believe that you are unreliable and unresponsive. Doors you wanted to walk through close.

Imagine that any time a challenge appears, the only way you can deal with it is by disconnecting in space, time, and identity. Gone are the abilities to ask for help, defend yourself, or protect people you care about. You just disappear.

Sometimes people end up relying on only one coping skill because it was the only skill that was useful—and lifesaving—in the past. Consider the child who grows up with a father who drinks large volumes of alcohol. When he starts roaring and the dishes shatter against walls near and far, hiding and dissociating are protective. And what if he drinks to this point of loathing and destruction most nights of the week? It seems safer to feel nothing at all rather than terror and tense muscles all the time.

The skills we use frequently—intentionally or not—are the skills we come to rely on.

Categories
Medicine Policy Public health psychiatry

Recent Readings.

(Note: There are two purposes to this post: One, to get back into a routine of writing and posting. Two, I moved my website to a different host (those of you viewing the actual website will see that the design is different). Because it will never be perfect (because what is?), I am posting as a public test to fix what needs to be fixed.)

Here are some interesting articles I’ve read recently, some of which are prompts for future posts here:

NPR: Stressed out about climate change? 4 ways to tackle both the feelings and the issues. I am largely unfamiliar with the literature on psychiatric conditions and climate change, though have read a paper or two (not recently) about the association of increased violence among people with increases in temperatures. I must also confess that that my current faith in psychiatry to address this in a practical way is brittle: Organized psychiatry (in the United States, at least) seemed unenthusiastic about supporting population mental health during the pandemic. Despite the urgent mental health consequences of Covid-19, organized psychiatry in the US seemed instead enamored with the topic in the next bullet point.

Wired: Is the Psychedelic Therapy Bubble About to Burst? A new paper argues that excitement has veered into misinformation—and scientists should be the ones to set things straight. I find myself feeling annoyed with the mushrooming ecstasy related to psilocybin and LSD (see what I did there?), among others. There are a number of reasons for this; I will be the first to state that some of my reasons are not valid. Much of my irritation stems from the limited evidence (at this time) to support psychedelics for more severe conditions, the limited number of people who can actually access this intervention (who can afford this? who has eight hours to spend with two therapists?), and why We as a Society do not instead invest in population-level interventions so fewer people will develop trauma-, depression-, and anxiety-related conditions (e.g., ensuring children aren’t hungry; supporting literacy and education so people have skills for employment; etc.).

The Hill: Suffering from burnout, doctors are working drunk or high on the job: report. A new report found the health care industry has been too slow to address its mental health crisis among doctors and nurses and often treats mental health as secondary to physical health. “Over the last three months, 1 in 7 physicians admitted to consuming alcohol or controlled substances at work.” This data came from interviews from a mental health company, so there’s potentially a lot of bias in the results. I am sorry to say, though, that I wasn’t surprised to learn this. Some health care workers were drinking or using controlled substances at work before the pandemic.

n+1: Lab-Leak Theory and the “Asiatic” Form. What is missing is a motive. I did not find this to be an easy read, though it engaged me enough that I was able to get through it. In short, the author, Andrew Liu, argues that the appeal of Covid-19 coming from a lab leak is a reflection of historical (and ongoing?) exoticization of the Orient, as well as fears of China’s economic power.

New York Times: Yes, We Mean Literally Abolish the Police. and Truthout: I Stole to Feed My Family and Was Incarcerated. We Need Resources, Not Prisons. I am not an abolitionist, though there are days when I wish I could be successfully persuaded to become one. (This reflects what appears to be my declining idealism as I age.) To be clear, I do not think incarceration has been or is an effective solution for many (and maybe most?) behaviors and problems. This conclusion comes from my experience working in a jail and with people who are poor and marginalized. However, examples easily come to mind for how law enforcement and incarceration have had some value: Consider Jeffrey Epstein or Ted Bundy. I don’t know what the answer is, though I do not think either pole (e.g., police state or abolition) are useful or desired solutions. I am open to changing my mind. (Related: This Twitter thread on the role of child protective services.)

New Yorker: The Lottery. Shirley Jackson wrote this short story in 1948 and I only learned of it in 2022! If you’ve never heard of it before, please go read it: It has excellent structure, which helps drive the story to its haunting and disturbing conclusion.