Category: Medicine

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Consult-Liaison Informal-curriculum Lessons Medicine

You Don’t Have to Like Everyone.

You don’t have to like everyone under your care. And you probably won’t, which is okay.

Own how you feel. If you insist on telling yourself that you should like someone when, in fact, you don’t, it will come out in other ways: The tone of your voice, the expressions on your face, the way you position your body.

There might completely understandable reasons why you don’t like the person under your care. Maybe he never seems to hear what you say. Maybe he doesn’t follow any of your recommendations, but he blames you for lack of healing. Maybe he expresses opinions you find offensive. Maybe he calls you racial slurs. Maybe he’s thrown things at you. Maybe he threatens to rape you. Maybe he’s told you that he will kill you and your family.

People do things like that for reasons that make complete sense to them. You may disagree with or misunderstand their reasons, but despite that, they are still people. Even though you may dislike some people under your care, you must still recognize that they are still human beings. The moment you refuse to recognize the humanity of the other person, you are at risk of inflicting violence upon them. Violence can manifest in many ways, including neglect.

First, do no harm.

It is possible to dislike someone and do no harm.

When we don’t like someone, it is much easier to assign blame entirely to the other person (e.g., “He’s an annoying @$$hole”). While it is possible that the problem has nothing to do with you and everything to do with the other person, that doesn’t change the fact that you cannot control other people. You can’t make someone less of an @$$hole. You, however, can make yourself view the situation in a different perspective.

Own how you feel. Let’s say he is, in fact, an @$$hole—something you cannot change. What if you focused instead on yourself?

“I really don’t like him. I feel dread whenever I have to see him.”

The reasons behind your dread make complete sense to you. When you acknowledge your dread and dislike to yourself, you give yourself more options as to how to proceed. You now have more control over the situation.

When you don’t like someone who is under your care and you acknowledge this, you can:

  • get support from your trusted colleagues. You can tell them how much you don’t want to see this person, how anxious and annoyed you feel about having to do this, and how much you don’t like this person. Get it out of your system ahead of time so you can be the professional you want to be when you actually see this person.
  • activate your internal coach. You can take some deep breaths and say a silent prayer before the interaction begins. You can rehearse some evacuation plans in case things start to run off the rails. Your internal coach can recruit your internal cheerleaders afterwards if the conversation goes well.
  • pause and remind yourself of your purpose. Your job does not include judging or shaming the person under your care. Your job isn’t to like the person under your care. Your job is to help the individual improve his health. Sometimes the people you care for have terrible life circumstances that contribute to the behaviors that you don’t like.
  • ask a colleague to see the individual so you don’t have to. Sometimes it is clear that the clinical relationship won’t work out at this time. We can’t be effective with 100% of the people we see (though we can try). Sometimes, the best way we can help the people under our care is to remove them from our care. (Sometimes, though, this isn’t an option.)

It’s often helpful to focus on the behaviors of an individual. When you focus on behaviors, you are more likely to remember and respect the person’s humanity. This keeps us professional and kind, even if we aren’t warm and smiling.

Indeed, he may do things that you don’t like… but he may also do things that you do like. And when we offer genuine thanks to people when they do things we like (e.g., “Thanks for your patience while I was asking you all of those personal questions,” “Thanks for summarizing your story quickly for me,” “Thanks for not calling me names today”[1. I have actually said, “Thanks for not calling me names today!” to people under my care and, no joke, the vast majority of them never address me with bigoted phrases ever again.]), people are almost always going to do those things more often.

You don’t have to like everyone under your care. Once you start owning how you feel, though, you might find that, most of the time, you do.

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Medicine Nonfiction Reflection

On Trusting Doctors.

There exists a particular physician who many in medicine regard as a quack: She has argued that HIV does not cause AIDS. She has written many pieces stating that vaccines are toxic and cause diseases such as autism, depression, and SIDS (sudden infant death syndrome). Within certain circles she enjoys great popularity. Her medical doctor credential lends her an authority that these circles highlight in their efforts to denigrate medicine.

I know her. Our paths crossed at one point during our medical educations. At that time, she and I worked in the same hospitals and saw people who experienced not only profound illness, but also suffering related to poverty, violence, racism, and other factors that impact health.

At that time, she believed the science that HIV causes AIDS. We never talked about vaccines, but I know that she believed the science of immunology and molecular biology. She and I, along with others in our cohort, exercised critical thinking when reading and discussing journal articles.

She and I were never close, but we were friendly. She was the first person to acknowledge my engagement. We were sitting across a table while someone gave a lecture. She pointed at her fourth finger, then pointed at mine, now adorned with a ring, and gave me a bright smile.

Many years have passed since we last saw each other. I wonder what happened to her.

To be fair, our beliefs and practices share some overlap: She apparently doesn’t prescribe medications at all. I try to avoid prescribing medications when possible. She has reportedly helped people come off of medications. I have, too. She encourages the application of exercise and other nonpharmacological interventions. I do, too.

From what I can tell, those are the few characteristics we now share.

If I am honest, I feel more anger than disappointment about her practice. As I understand it, she apparently charges over $4,000 (yes, over four thousand dollars) for an initial evaluation (that lasts for two hours) and one follow-up appointment. Every 45-minute follow-up thereafter costs almost $600. It also sounds like that people who wish to see her must fill out a questionnaire, which she uses to screen people into or out of her practice.

How many people can afford to pay $4,000 for an initial evaluation? Yes, I understand how scarcity makes something or someone seem more valuable, but $4,000? People who can pay that amount—plus the $500+ for each follow-up appointment—have access to other resources that make options other than medication possible. Furthermore, if her screening questionnaire weeds out people who want (or need) to take medication, that means she is unlikely to see people with moderate to severe symptoms.

Most people don’t want to take medications. Most people try everything they can with the resources they have before seeing a doctor. Unfortunately, the current healthcare system drives and rewards physicians for prescribing medications, even when that isn’t the optimal intervention.

Furthermore, this $4,000+ results in the potential spread of false information. I don’t know what she’s doing during that initial assessment—my guess is that it involves a lot of listening—though I doubt she’s persuading everyone to avoid vaccines or that HIV doesn’t cause AIDS. I don’t know; maybe she is. Though, given her popularity in certain circles, selection and confirmation biases are already active: Only those individuals who already share these beliefs would seek care with her.

As much as the above bothers me, what irks me the most is the seeming waste of her training and talent. Our training paths crossed, yes, but look how they have diverged! She charges literally thousands of dollars to provide care for people who are unlikely to experience significant symptoms. Given the economics of her model, most of the people she sees are likely upper middle class to upper class white people.

The individuals under my care, both past and present, are often people of color with significant symptoms who have few resources, often through no fault of their own. For those who don’t wish to take medicine, we work together to help them obtain a job, secure housing, or avoid the attention of the police. Those individuals who take medicine often find that their quality of life improves by leaps and bounds: They are able to stay out of the hospital. They remain employed. They spend time doing the things that matter to them.

To be clear, upper middle class and upper class white people also experience severe psychiatric conditions. Major psychotic, mood, and substance use disorders don’t discriminate. People without money and access to resources, though, are likely to fall farther and have a harder time catching up once symptoms appear.

Let’s assume for the moment that this particular physician who charges $4,000+ for an evaluation has developed a treatment model that really helps people without the use of pharmacology. Why not share that model? Why not work with researchers and other physicians who can adapt this model to people who can “only” afford $500 for an initial consultation? Or $100? Or $5?

This physician knows how to work with and provide successful treatment to individuals with major mood and psychotic disorders. I’ve seen her work. While I have no doubt that the individuals who are able to spend $4,000 on an initial evaluation are suffering, what about all the other people who suffer who will never be able to afford that consultation? If the treatment model really works, why limit it only to the people who have that kind of money?

Why not ease the suffering of as many people as possible?

Could it be that the powers of confirmation bias, scarcity, and placebo are the keys behind her treatment model? That $4,000+ buys chiefly status and expectation? Does it matter that unfounded, dangerous claims are part of the deal?

Should you always trust a doctor?

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Consult-Liaison Education Medicine Systems

The Social History.

From the notes I read, it seems that other medical specialties limit “social history” to whether or not someone uses tobacco, drinks alcohol, or uses drugs.

“Social history” is meant to get a sense of the context in which people live. Where do they live? Who do they live with? How did they come to live there? Where did they grow up? What sort of work do they do? How much school have they finished? What do they do for fun? What are the important relationships in their lives? etc.

I almost always start my clinical interviews with the social history. There are several reasons why I do this:

One, it’s a more neutral place to start. My hope is that it will help the person feel more comfortable talking to me. Most of these questions are easy to answer, since many of them overlap with social conversation: Where do you live? How long have you lived there? This is also an opportunity to communicate through non-verbal communication: The nodding, the eye contact, and all the other behaviors that show that I’m paying attention and worthy of trust. (“See, it’s not so bad to talk with a psychiatrist.”)

Two, it puts the information the person shares with me into context. If people don’t have a stable place to live, then they have good reason to feel anxious about their safety and exhausted from poor sleep. If someone lives with other people who are struggling with substance use or are often fighting, then this person may not be able to recruit them to help with the tasks of daily life. They may not even feel safe staying with them, but don’t have other choices. One can’t expect someone to take medication on a regular basis when they don’t have enough money to buy food.

Three, if people don’t want to talk to me for whatever reason, the way they stop the conversation is useful information. Sometimes people are paranoid for a variety of reasons—some based in reality, some not—and they shut down the interview. Sometimes people want to talk to me, but they’re exhausted and ask me to come back later. Sometimes people don’t like something about me: my hair (it’s noteworthy how some people respond to my hair), my ethnicity, my clothes, my sex, the way I talk. I can’t change most of those things, and how people respond to all that tells me (1) how I can better interact with them in the future and (2) what might be going on that is causing them to respond this way. And sometimes people don’t want to talk to me because I’m not conducting the interview in a skillful way: Maybe I’m coming across as cranky, uncaring, or judgy.

Four, and most importantly, I want the person to know that I view them as a human being. I wince whenever someone immediately launches into their mental health history: “Okay, I have a diagnosis of schizophrenia and I take Zyprexa and Cogentin….” This tells me that this person got the message over time that no one is interested in him as a person; people only want to know his diagnosis and medications. But people aren’t their diagnoses or their medication regimens. All people have hopes and dreams; they have things they want to do and people they want to be. While a summary statement might make the interview more efficient, it matters whether this person volunteers at the animal shelter every week because he loves dogs or whether he stays at home and watches TV all day. This information is valuable, regardless of his diagnosis.

It takes time to get a social history. Short appointments, though, are short-sighted. It’s much faster to generate diagnoses from labs and studies; it’s much faster to write prescriptions than to listen to patients. If physicians don’t get an accurate history, then physicians are more likely to generate wrong diagnoses. Wrong diagnoses, along with no information about the contexts in which people live, lead to wrong interventions. Did anyone then actually save any time?

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Informal-curriculum Medicine Nonfiction Seattle

My Seattle Times Op-Ed about #MeToo in Medicine.

The Seattle Times published an op-ed I wrote! Their editorial staff provided the title, #MeToo in medicine: ‘Who would believe a trainee?’

I wonder: What if I had a different byline? Would the Seattle Times have published it if I worked as a nurse? medical student? medical assistant?

What if I worked as a janitor in a hospital? Or in housekeeping?

What if I waited tables? worked in retail? had a job that is “off the books”?

The last sentence in my op-ed is “I was fortunate, but not all women are.” I was fortunate in that I had support from supervisors and colleagues, and that the psychiatrist in question didn’t do anything worse.

I remain fortunate, though, in that I have the privilege to be able to share this story to a wider audience. I have access that other people lack. And those are the people we should consider about when we talk about “#MeToo”.

The senior psychiatry resident at the University of Washington School of Medicine warned me ahead of time. She laughed as she said, “He’s weird. You’ll get used to him.”

When I first met with him, the psychiatrist lazily spun in his chair, his left hand tucked into his pants, his thumb hanging out. After he told me his expectations as my supervisor, he patted my right thigh as he ended the meeting.

I spent one day a week training in his clinic. He often put his hand on my shoulder. If he sat near me, he extended his arm to pat my leg. When I sat far from him, he crowed compliments in front of patients and other staff: “Dr. Yang is one of the best residents who has ever worked with me!”

He began to send emails to me at all hours of the day and night. They stopped referring to clinical research and developments; now he wrote of art, history and music that he thought I would enjoy. Some of the timestamps on his emails were near 2 a.m.

“Do as I say, don’t do as I do,” he chided in his emails. “Good night.”

My discomfort increased over time, though I wondered if I was overreacting. After all, didn’t another resident tell me that he was weird? She didn’t seem distressed with his behavior. Maybe I was too sensitive.

I asked two other supervisors, both psychiatrists, for advice. The male psychiatrist was angry and swift in his response: “You have to tell your residency director. This isn’t right.”

The female psychiatrist wavered. “I don’t know,” she said after a long pause. “It’s up to you if you want to say something. It could turn into a ‘he said, she said’ issue.”

She had a point: Who would believe a trainee over a tenured professor? Would he retaliate? How would this affect the rest of my training?

I decided to talk with him first. My request seemed reasonable: “Could you please stop touching me and stop sending emails to me that are unrelated to clinical work? I feel uncomfortable when those things happen.” I rehearsed.

The next time I saw him, he greeted me with a pat on the shoulder. I felt my face flush as I stammered, “Could you please stop touching me? It makes me feel uncomfortable.”

He paused, then smiled. “Why didn’t you tell me sooner? It’s not that big of a deal. I’m just being friendly.”

It was a big deal: He stopped talking to me entirely when we were in front of patients. He stopped teaching me. At what would become our last meeting together, he refused to acknowledge my concerns about a clinical issue. It seemed like he was trying to pick a fight with me. We fell silent. He looked at me with amusement. I glared at him.

“Are we done?” I still felt like I needed his permission to leave.

“Yup!” He grinned. It was clear I had to talk with my residency director.

She believed me. She was swift and immediately pulled me from the rotation.

One of my fellow trainees, a robust man who played football in college, was assigned to work with him for the following six months.

My fellow colleague believed me. He was swift. He objected and asked for another rotation, stating that he didn’t feel comfortable working with a physician who had mistreated another trainee.

The psychiatrist ultimately left the institution, following an administrative leave.

Sexual harassment occurs in every profession, even medicine. To stop this, we need as many people as possible — men, women, colleagues, advisers and leaders — to support women and act swiftly when these events occur. I was fortunate, but not all women are.

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Consult-Liaison Education Medicine

Thoughts about the Digital Pill.

Reader and stellar nurse Natalie[1. I know Natalie is a “stellar” nurse because we used to work together.] wondered about my thoughts about the digital pill.

My initial reactions were similar to several of those who were interviewed for the article. The digital pill, which provides electronic information to confirm whether someone has ingested the medication, has great potential to become a tool of coercion. Aripiprazole (Abilify) is classified as an antipsychotic medication, which is often prescribed to people who have beliefs that machines and other surveillance tools are in their bodies. Why would the nascent technology of a digital pill make its debut for this population?

I have several other concerns about this digital pill:

(1) The purported mechanism of action for aripiprazole (Abilify) involves hand-waving, which is yet another reason why its debut as a digital pill is perplexing. To the manufacturer’s credit, the package insert for arpiprazole is blunt: “The mechanism of action of aripiprazole in schizophrenia or bipolar mania, is unknown.” (Section 12.1.) The explanation in the scientific papers, though, gets those hands waving all over the place (warning: technical language fast approaching):

The development of D2 partial agonists is a logical strategy for the treatment of schizophrenia because the pathophysiologic mechanism of schizophrenia is thought to be based on too much dopamine activity in some regions of the brain and too little dopamine activity in other regions. A D2 partial agonist can act as a functional antagonist in areas of high levels of dopamine, such as the mesolimbic pathway, but not in areas of normal dopamine levels, such as the nigrostriatal and tuberoinfundibular pathways. Thus, a D2 partial agonist is expected to reduce the positive symptoms of schizophrenia without producing movement disorders or elevated prolactin levels. In regions of low dopamine concentration, such as the mesocortical pathway, a D2 partial agonist will show functional agonist activity.

Put into plain language, what all that means is aripiprazole might stimulate specific receptors in one part of the brain, but block those same receptors in other parts of the brain. The concentration of dopamine might determine whether aripiprazole stimulates or blocks those receptors.

I’m skeptical.

That’s like an antibiotic that only kills one specific type of bacteria in one part of the body, but doesn’t kill that same specific bacteria in other parts of the body.

How does that work? Especially since science has yet to determine the underlying causes of psychotic disorders, such as schizophrenia?

So, in sum, this is a digital form of a medication that has an uncertain mechanism of action for a disease that we don’t fully understand.

What?

(2) The focus on adherence to medication assumes that the ingestion of medications is the most important aspect of treatment. This may be true for some individuals, but does not apply to everyone. Psychiatry focuses on maximizing function and quality of life. Sometimes people can attain both without taking digital pills daily.

(3) Most people under my care don’t have access to technology like smart phones. Some of these individuals also have the most severe symptoms and are the most likely to benefit from a variety of interventions: Skills coaching, housing, nutrition, exercise, art, and talk and behavioral therapies, in addition to medication.

(4) I don’t know how the data from this digital pill will actually change care. Psychiatry, for now, still relies on the observation of thoughts, emotions, and behaviors of people. Whether someone is taking their medications or not may not actually change treatment plans.

For example, say Natalie is under my care and takes a digital pill. I learn that Natalie takes this medication five days out of seven. All sources report that she’s doing okay: She’s getting along with her family, is going to school or work, is keeping up with her rent, and continues to follow the blogs she likes. Do I encourage her to take the medication every day? What more gains might she make? What if it detracts from her quality of life to have to take a medication every day, particularly when she’s doing okay?

Or, what if the digital pill tells me that Natalie hasn’t taken medications at all since I prescribed them to her? And Natalie continues to experience significant symptoms? I guess it’s helpful to have confirmation that Natalie isn’t taking medication, but, if I have sufficient rapport with Natalie, she’ll straight up tell me that she’s not taking it. Why use a digital pill when I can get the information from someone directly? Particularly when she can tell me the specific reasons why she doesn’t want to take it?

Or, what if the digital pill tells me that Natalie is taking the medication everyday, but she also continues to demonstrate significant symptoms? Again, the confirmation that she’s taking her medications could be helpful, but if I have rapport with her and she continues to suffer from symptoms, it’s likely that she would tell me this information, anyway.

If physicians want people to trust them, then physicians must show that they trust the people under their care. There are easier and more compassionate ways to get accurate information without resorting to a digital pill.

(5) Lastly, who are we actually treating with this digital pill? Who is going to feel better with the data the pill generates?

This data won’t tell individuals anything they don’t already know. They will know if they took their medications or not. (And savvy patients will figure out a way to subvert this digital pill reporting: Maybe they will give the meds to a pet or to another person.) This data is meant to help physicians feel better, not patients.

If the goals of psychiatry are to help reduce suffering, improve function, and help people live the lives they want to lead, we cannot rely on medications alone to achieve this, particularly for those individuals with significant symptoms. Even if the data shows that someone is taking medications daily, that process measure is meaningless if the person’s overall function and quality of life remains poor.