Category: Medicine

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Medicine Nonfiction Reflection

Compassion?

I met him about a month before the election. He was confused. He spoke only about three things:

(1) his best friend, with love and affection
(2) his culinary skills, with pride and wistfulness
(3) Donald Trump, with exasperation and anger

“When’s the last time you and I spoke?” I asked.

“Uh, I don’t know… maybe a few days ago?” he guessed.

I had stepped away for only ten minutes.

In the weeks leading up to the election, I introduced myself each time. Each time he said that we had talked “just a few days ago”. At the end of each conversation, he extended his hand and said, “It was so nice to meet you!”

After repeating the ingredients of his prize-winning chile cocoa tacos (“cocoa powder! cumin! cinammon!”), he lurched into politics.

“Donald Trump! We can’t have Donald Trump! He’s not a good man. I won’t be voting for Trump! Not a good man. Not a good man.”

Perseveration, check.

Sometimes he would lurch back into prize-winning chile cocoa tacos; sometimes he would express his appreciation for his best friend (“I just want to see him again… when am I going to see him again?”). Sometimes he would look at me, pause, and then start talking about Bruce Lee.[1. I can’t tell you how many times people with psychotic or cognitive disorders look at me and then start talking about Bruce Lee. Sometimes they tell me I look like Bruce Lee’s sister. (I don’t look like him.) Sometimes they ask me if I know kung fu like Bruce Lee. Sometimes they speak highly of his films.]

Days after the newspapers splashed the results of Presidential election all over their front pages, we met again.

“Hi, I’m Dr. Yang.”

“Hi! It’s so nice to meet you. How are you doing?”

“I’m doing okay. How are you?”

“Donald Trump is ahead, can you believe it? I thought Hillary would be ahead by a lot, but Trump is ahead! Can you believe it?”

“Do you know who won the election?”

“It’s not over yet, they’re not done counting the votes. But Trump is ahead! I can’t believe it! I thought Hillary would be ahead by a lot—”

“Is the election over?”

“No, it’s not over yet, they’re not done counting the votes. But Trump is ahead. Can you believe it? Hillary still has a chance—”

“When is the election supposed to be over?”

“I don’t know, but Trump is ahead! Can you believe it? ”

One of the best things you can do for someone with memory problems is tell them information about “now”. Remind him what the date is. Tell him what time of day it is. Point out the seasons, talk about the city he’s in. Tell him who the President-elect is.

I looked at him as he continued to talk about the election. He still had hope.

I inhaled, smiled, and interjected, “So, you used to be a cook, right?”

“What? Oh, yes! I won a prize for chile cocoa tacos….”

Categories
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.

Categories
Education Medicine Nonfiction Observations Systems

A Day in Jail.

Three of us are waiting for the elevator. A few moments earlier I had walked into the jail for the day, so I have not yet donned a white coat. The other two are wearing their standard uniforms: The inmate is in red and the officer is in black.

“I have to take my seizure medicine while I’m here, you remember, right?” the inmate says, clutching a clear bag holding several pill bottles, a pair of jeans, and a dark jacket.

“Yes,” the officer says, her voice warm and firm at the same time. “You told the nurse, right?”

“I always do, ma’am.” A shy smile crosses his face. She smiles back at him as the elevator doors open. She motions for him to enter first.

The hem of the white coat hits the back of my calves as I climb the stairs. My habits from my intern year remain: I still fold papers in half lengthwise and the first stack will go into the left pocket. I never button my coat.

When I reach the top of the staircase, one of the standing inmates glances at me, then returns his gaze to the inmate seated in front of him. The standing inmate looks like he’s in his 20s. The seated inmate might be in his late 30s. Twenty-something guides the electric razor along the contour of Thirty-something’s head; clumps of light brown hair tumble onto the black cape and the concrete floor.

There are two barbers on duty. They volunteered their services; they will probably get extra food as compensation. The men in the chairs bow their heads, their eyes open, their bodies still. No one says anything.

Everyone gets the same haircut.

The floor officer is worried about an inmate: “He didn’t eat breakfast this morning and wouldn’t come out to take a shower.” While I scribble this information down on my paper folded lengthwise, I hear the deck officer raise his voice.

“What are you looking at?” the deck officer barks at two inmates. They are trustees, which means that they have demonstrated good behavior while in jail and are allowed to participate in chores. In exchange for doing tasks such as preparing meals and cleaning floors (which also gets them out of their units), they can receive more food .

A trustee mumbles something in response.

“I asked you, what are you looking at?” the deck officer barks again.

“Nothing, sir.”

“Okay. If I see you looking at ‘nothing’ again, I’m sending you back. Do you understand me?”

“Yes, sir.”

“Get back to work.”

The floor officer and I ask the deck officer what happened.

“They saw you,” he says, pointing at me, “and started grinning, elbowing each other, all that stuff.”

While wrapping my coat tighter around me, I glance at the two trustees. One of them happens to look at me at the same time; he turns away and takes a sudden interest in the mop in his hands.

“Thank you, Officer.”

“Just looking out for the doctor.”

It’s been a few years since I’ve talked to God.

Perhaps I meet God more frequently, but s/he chooses not to reveal that to me. More often I talk to angels or the Anti-Christ.

“Psychiatry is sorcery,” God tells me. “If you only had more faith, you would see the error in your ways. Turn towards faith and away from your analytical ways of thinking.”

God is charged with criminal trespass. God is a young man. His bail amount isn’t that high. Is there no one in God’s life who could post his bail so he could get out?

“One of the best things about being God,” he tells me, “is that I can see the true intentions of people. I know their thoughts.”

He pauses and looks at me.

“Although you practice witchcraft, I can tell that you’ve got a good heart. I will pray for you that you will have more faith, that you will believe in me.”

I will pray for you, too.

When I’m finished talking with God, the floor officer comes by and gives God a second lunch.

“Thank you! I bless you!” he calls out.

The brown paper sack contains one sandwich (two slices of wheat bread, one slice of bologna), one mayonnaise packet, one slice of American cheese wrapped in plastic, a small baggie of baby carrot sticks, and one apple the size of a tennis ball.

“He’s still growing,” the floor officer murmurs.

The day has ended. I’ve already stuffed my white coat into a laundry bag, but I’m still making my way through all the doors to physically get out of jail. When I exit the elevators near where inmates are booked into jail, I see an officer wincing and grasping his leg. One medic is kneeling by him; the other is on the phone.

I pass by a bank of holding cells. Two women knock on the wall and beckon me towards them. The one with tattoos all over her young face and anxiety in her eyes asks, “Can you tell them to let us out? We’ve been waiting a long time.”

“An officer looks hurt,” I say, raising my voice. We’re talking through a thick pane of plexiglass. “The medics are here. It might be a while before they will get to you.”

“Oh,” she says. They take a step back and their shoulders slump. “I hope they’re okay. Thanks.”

Most people look either relieved or thrilled when they leave jail. They throw their shoulders back as they cross the threshold from the jail lobby into the fresh air. How much more comfortable they appear in their own clothes! The red uniforms incarcerated them just as much as the concrete block. Sometimes they give each other high fives; their voices are light and bright as they tell each other to take it easy.

A few will look up and around, confused and forlorn. They squint at the numbers at the bus stop. After taking a few steps heading south, they pause, turn around, and head north. They finally decide to cross the street to get away from the jail. It seems like the best idea.

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Consult-Liaison Education Medicine Observations Policy Reflection

Why I Agree with the Goldwater Rule.

The New York Times and NPR recently published articles related to the Goldwater Rule. In short, a magazine sent a survey to over 12,000 psychiatrists in the US with the single question of whether they thought Presidential nominee Mr. Barry Goldwater was fit to serve as President. Few psychiatrists responded. Of those that did, more than half—still over 1,000—said that he was not. Mr. Goldwater ended up losing the Presidential race, but he sued the magazine over this… and he won. Thus, the American Psychiatric Association has advised that psychiatrists should not diagnose public figures with psychiatric conditions. Some psychiatrists have felt otherwise for the current Presidential election.

There is a hypothetical concept in psychiatry called the “identified patient“. It is most often applied in family systems. For example, consider a family that consists of a mother, a father, a son, and a daughter. The parents bring the daughter to a psychiatrist and say that she has worrisome symptoms. Maybe they say that she is always angry, doesn’t get along with anyone in the family, and does everything to stay out of the house. The parents and the son argue that there must be something wrong with her.

As the psychiatrist works with the family, the psychiatrist learns that the parents have the most conflict. The daughter may have developed ways to cope with this stress in ways that the parents don’t like. Because the parents have the most authority in this system and do not recognize how their conflicts are affecting everyone else, they assume that the daughter is the problem. To oversimplify it, the daughter becomes the scapegoat. The daughter is the identified patient.

Presidential nominees don’t become nominees through sheer will. There is a system in place—putting aside for now whether we think the system is effective or useful—where the American public has some influence in who becomes the ultimate nominee. Candidates are eliminated through this process.

Does the Presidential nominee actually have psychopathology? Could a nominee rather reflect the public that supports him or her? Could it be more accurate to describe the nominee for a specific party as the “identified patient”?

Erving Goffman presents an argument in his book The Presentation of Self in Everyday Life that has similarities with the monologue in Shakespeare’s As You Like It:

All the world’s a stage,
And all the men and women merely players;
They have their exits and their entrances,
And one man in his time plays many parts

Goffman and Shakespeare are both commenting on the presence and importance of performance in our daily lives. Goffman argues in his text that context matters[1. I agree that context matters. See here, here, and here.]. We all do things within our power to alter ourselves and the contexts to present ourselves in certain ways.

Some mental health professionals have argued that we can diagnose public figures with psychiatric conditions because of “unfiltered” sources like social media. While it may be true that some people are more “real” (or perhaps just more “disinhibited”) on social media than others, that does not mean that people are revealing their “true selves”. Do you think that people are always eating colorful vegetables in pleasing arrangements? or that people are always saying hateful things, even while waiting to buy groceries, attending a church service, or folding laundry? or that their cats are always cute and adorable, that hairballs and rank breath have never exited their mouths?

Lastly, the primary purpose of diagnosis is to guide treatment. There is no point in considering diagnoses for someone if you’re not going to do anything to help that person.

People have commented that psychiatric diagnoses often become perjorative labels. Unfortunately, there are those who work in psychiatry who will use psychiatric diagnoses as shorthand to describe behavior they don’t like. Instead of saying, “I feel angry when I see her; I don’t like her,” they will instead say, “She’s such a borderline.” That’s unfair and often cruel. If you’re not going to do anything to help improve her symptoms of borderline personality disorder, then why describe her that way? (We’ll also put aside that such a sentence construction reduces her to a diagnosis, rather than giving her the dignity of being a person.) If we are serious about addressing stigma or sanism, then we should only use diagnosis when we intend to help someone with that diagnosis.

I agree with the Goldwater Rule, though not because of the exhortations of the American Psychiatric Association.[2. I’m not a member of the APA. The reasons why I am not a member are beyond the scope of this post.] Diagnosis should have a specific purpose. We often do not have enough information about public figures across different contexts to give confident diagnoses. Presidential nominees are often appealing to various audiences, which can both affect and shape their behaviors. Most importantly, giving a diagnosis to a public figure without any intention of helping that person doesn’t help anyone, especially those who would ultimately benefit from psychiatric services.

Categories
Education Medicine Policy Systems

Inspiration from the Surgeon General.

Somehow people knew he was about to enter the room. The thirty or so people in the room were seated, though people began to stand up.

“Are we supposed to stand up for the Surgeon General?” I asked the person sitting next to me.

She shrugged. If we remained seated, everyone would have noticed. So we stood up.

“I’ve been in this position for a year and a half,” Dr. Murthy said, “and I’m still not used to people standing up for me. Please sit down.”[1. I learned later that the Surgeon General has the rank of a Vice Admiral, as the role oversees uniformed health officers. That’s why people stand up for the Surgeon General.]

We were all in that room for about an hour, but Dr. Murthy said little. After some opening remarks about the Turn the Tide initiative related to the opioid epidemic, he asked the audience to tell him what was going well and what could use improvement.

I had never met him before, but I was immediately struck with his listening skills. It was as if he was taking a history from a multi-person patient. He made and held eye contact. He didn’t fidget. He spoke in a quiet yet firm voice. Though he didn’t come across as warm, it was clear that he was interested in and paying attention to whoever was talking to him. His thoughtful follow-up questions indicated that he was listening to what people were saying to him.

He seemed like a good doctor.

As I had never met a federal official before, I later learned that Dr. Murthy was also unusual in that he took notes. (Fun fact: He’s left handed.)

“These are usually publicity events without a lot of substance,” a more seasoned co-worker commented.

By the time the meeting was over, he had covered a sheet from a yellow notepad with copious notes. He expressed what seemed like genuine thanks to us for our time and perspectives.

It was through luck only that I was there. A colleague told me a few days prior that the Surgeon General was scheduled to speak to a local task force related to the opioid epidemic.

“The Surgeon General?” I blurted. “I’d love to hear what he has to say.”

“Then you should come.”

“What?”

Afterwards, as the Surgeon General’s staff were trying to hustle him out the door, the same colleague who invited me to this event gave me A Look. Only I could see the thought bubble above his head: “Go ask him for a photo!”

Though I appreciated Dr. Murthy’s humility, thoughtfulness, and professionalism, I was also grateful and amused with his willingness to stop for a photo.

Earlier that day I was seeing patients.

“Do you know how much longer you’re going to be jail?” I asked.

“Ten or eleven days.” He looked at my left hand. “You’re married?”

“Yes.”

“I should start going to NA meetings again. I’m never gonna meet a woman in here and I get so depressed about not having a family. I want a wife and kids, like my brother. I don’t know why he got so lucky and I got screwed. The TV doesn’t talk to him, he’s got a wife and three kids, God blesses him, but I will wait because the meek shall inherit the earth—”

“What do you think will help you not pick up when you get out?”

He shrugged. “I still don’t have a place to live. Dope helps me feel better.”

We looked at each other and said nothing.

The reality is that the Surgeon General (or any other public official) is just one person. Though he has a grand title, he alone cannot make improve health care. He is part of a system. We can only hope that he and his office will be able to shift the system—even if only just a bit—so that it works better to serve the US population.

What the Surgeon General can do and, at least for me, has done, is inspire physicians to get involved and do better. He could have swept into the meeting and spoke at length about his accomplishments and his status within the federal government. He instead presented himself as a humble ambassador and servant. He demonstrated interest in what our locality has witnessed and experienced. He recognized that, even though he was an academic physician, he is now too far removed from clinical care to speak first as an expert. He solicited and accepted feedback, some of which was discouraging. He was professional. He wasn’t defensive. He acknowledged that it may seem like our feedback would disappear into a void in Washington, DC, though everything else he was actually doing during the meeting gave us hope otherwise. It’s quiet leadership.

There are a lot of problems with health care. Physicians and patients both know this. Physicians are trained to take care of people, not to create and manage financial systems that should only support the relationships between physicians and people. However, if physicians are not involved in the conversations about these systems, then we are not advocating for the patients we serve and the profession that gives us the privilege of doing so. Yes, I know we’re too busy taking care of patients to participate in these conversations that can seem bloated and irrelevant. However, if we don’t get involved to define the problems and solutions, how could we ever expect these systems to improve?