Category: Medicine

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Consult-Liaison Medicine Observations

Chart Notes.

While reviewing old chart notes, I frowned as I learned how distressed the patient had been while he was in the emergency department. Without realizing it I murmured a line from a physician’s note:

Rambling historian, only clear complaint is hunger.

A colleague, who is often hungry, overheard me and responded, “That would be my mental status exam.”

A different chart provided this information:

Patient started getting agitated and threw a bagel at staff.

I couldn’t help but snort with amusement[1. All of us who must write clinical notes often dilute details because they’re often not relevant to clinical care, though these details often add context to what happened. Like the writer of this note, I often include factual details without intending to be funny. Sometimes we laugh because we otherwise would feel overwhelmed with sadness, anger, or helplessness.], though then wondered:

  • Was it a whole bagel?
  • Was it an old, stale, and hard bagel?
  • Did the bagel have cream cheese on it?
  • Was it thrown like a frisbee or like a baseball?
  • Did the bagel actually hit anyone?
  • What happened that led the patient to throw the bagel?
  • Did the patient elect to throw the bagel instead of an open carton of milk? or a single serving of jelly?

Yet another chart included this terse note from a medicine resident in the early hours of the morning:

Interval exam changes. Agitated overnight. Double middle finger to providers. Haldol 5mg IV ordered and given.[2. For those of you who are interested, Haldol 5mg IV equals Haldol 10mg PO (by mouth), which is a standard dose for someone with a diagnosis of schizophrenia. The thing about Haldol 5mg IV is that sometimes doctors order this with the intention of inducing calm in a patient so he doesn’t punch staff, destroy property, hurt himself… but, sometimes, the patient instead becomes sedated and is in a deep sleep for many hours. The goal should be to calm, not snow, the patient.] PRN Ativan.

One would hope that a patient doesn’t receive a sedating antipsychotic medication simply for extending both middle fingers to doctors and nurses!

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Medicine Nonfiction Observations Seattle Systems

On What Medical Directors “Should” Look Like.

I recently answered a survey about race. One question asked:

“If you ask to speak to the leader of your organization, can you expect to see someone of your race?”

I snorted. I didn’t mean to. I just had never thought about that before.

In my previous job my title[1. As I have noted elsewhere, “titles, at the end of the day, are just words.“] was “medical director”. During the first few months of that job the title felt alien to me. It was as if people at work said, “Oh, Dr. Yang? She’s the one over there with the blonde hair.” Meanwhile, I’d touch my black locks, feeling perplexed.

Early on I conducted interviews to hire staff. One applicant, a psychiatrist, was a Caucasian man in his early 50s. His greying brown hair was cropped close to his head. A striped burgundy necktie adorned the light blue dress shirt underneath his navy blue suit. Cuff links poked out from under his sleeves. A silver pen was clipped into the breast pocket of his jacket.

Turning to the program manager, I murmured, “THAT guy looks like a medical director, not me!”

She, a Caucasian woman, laughed before she said, “Yeah, you’re right!”

In the jobs I’ve held the medical directors have all been Caucasian males, with the exception of my first job: He was Asian. In residency training the chair of the department was a Caucasian male. The paintings and photographs of leadership that lined the halls of the medical school were all of aging Caucasian men.

That’s how I came to learn that medical directors don’t look like me; they’re older white men.

Leadership at this agency believed I had sufficient qualifications and hired me, an Asian female, to serve as the medical director. However, the idea that someone in this position “should” be an older white male persisted in my mind.

What does it mean that I felt doubts about my ability to work as a medical director simply because of the way I look?[2. While this post is focused on race, it could easily focus on sex, too: Most medical directors are men.]

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Consult-Liaison Education Medicine Observations Policy Systems

Buprenorphine and Other Controlled Substances.

I recently completed the buprenorphine waiver training. Buprenorphine, itself a partial opiate, is a medication that can be prescribed to patients who have opiate use disorders (e.g., taking Oxycontins or injecting heroin to get high). A physician must complete an eight-hour training and take an exam to become eligible to prescribe this medication. The physician must then apply for a specific “X license” through the DEA to prescribe it.

In some ways treatment of substance use disorders is the most evidence-based practice in psychiatry. When talking about opiate use disorders, for example, we can talk about specific mu-opioid receptors and their roles in pain and intoxication. We can discuss how drugs—both illicit and licit—work on these receptors and why certain medications can reduce or eliminate illegal drug use. This logic satisfies the analytical mind.

Since completing this training I have wondered: Why must one undergo a specific training and obtain a separate DEA license to prescribe buprenorphine?

With my current licenses I could prescribe all forms of pharmaceutical morphine (e.g., Oxycontin and Dilaudid), which can lead to severe physical and psychological dependence. Which could then result in the intervention of buprenorphine.

As a psychiatrist I would likely arouse the suspicions of the DEA if I prescribed opiate medications. That’s outside the scope of a psychiatrist’s practice.

However, it is not outside of the scope of a psychiatrist’s practice to prescribe benzodiazepines (e.g., Valium and Xanax), which are Schedule IV drugs (“a low potential for abuse relative to substances in Schedule III”).[1. You can learn more about controlled drug “schedules” on the DEA website.] I can also prescribe Schedule II drugs (“high potential for abuse which may lead to severe psychological or physical dependence”), such as Adderall and Ritalin. Physicians are not required to go through any special training or obtain separate licenses to prescribe those medications. Once I got my DEA license, I was free to prescribe these without anyone looking at me askance.

And, get this: buprenorphine is a schedule III drug!

The training offered the Harrison Narcotics Tax Act of 1914 as one reason behind the training requirement: This law suggests physicians can prescribe opiates as part of “normal” treatment, but not for treatment for addiction. Addiction was not considered a disease in 1914. Thus, if addiction is not a disease, no intervention is indicated.

That explanation, however, doesn’t make sense. There is growing consensus that substance use disorders are diseases. Nothing, other than my good judgment, prevents me from cranking out prescriptions for stimulants and benzodiazepines. Use of either medication can lead to addiction. What makes opiates so special?

The consequences of the buprenorphine training are not slight: The eight-hour training alone likely deters some physicians from pursuing it. The extra licensure is also an obstacle, as well as the consequences of using the license: No one wants regular, but unannounced, DEA audits (which, just to be clear, doesn’t happen with when one prescribes benzodiazepines or stimulants). No one is eager to maintain the documentation that is required when one prescribes buprenorphine.

It just makes me wonder what the actual story is….

Categories
Medicine Observations Policy Reflection Systems

On “Mental Illness”.

I’ve been invited to speak to a group of attorneys who work at the interface of psychiatry and the law. The topic of my talk? “Psychiatry 101.”

A psychiatrist who gave this talk to a similar group a few years ago advised me: “You should assume that lawyers are laymen. It’s surprising how little they know, given the work that they do.”

This teaching opportunity to teach has given me pause: What is mental illness?

Most of my work has been with people with few resources (no home, no job, etc.) or with people who are experiencing symptoms that cause significant distress (they won’t eat because they think all food is composed of their internal organs; they often try to kill themselves due to hearing voices telling them to do so; etc.). Most people would agree that these individuals have “mental illnesses”, whether “caused” by their circumstances (imagine people trying to set you on fire or rape you because you are sleeping outside) or by apparent biological events (imagine a freshman in college with an unremarkable history who, over the course of months, begins to believe that the government inserted a chip into his brain).

I have also worked in settings where:

  • a wealthy man’s wife felt overwhelmed with anxiety about which of their three homes they should remodel first
  • a aerospace engineer with no symptoms wanted to try an antidepressant because his girlfriend started taking one and she now seemed to have greater clarity of mind; “maybe that will happen to me, too”
  • a college student felt depressed because his parents wanted him to pursue a professional degree, but he didn’t want to do that

Do those individuals have mental illnesses? Does psychological suffering equate to mental illness? Even if they are able to get on with the necessary details and difficulties of life?[1. Do not misunderstand: People with means can and do have mental illnesses. Take the software developer who was certain that public surfaces were contaminated with exotic diseases; he couldn’t get himself to go to work or spend time with friends due to fears that he would get sick and die. Or the accountant who, if she doesn’t sleep enough, would believe that she is the mother of God; she went to hospitals insisting that she was in labor with Jesus when, in fact, she was not pregnant.]

My mind then spins to recent events, such as the Germanwings place crash. Many people have argued that, because the co-pilot killed people, he was mentally ill. He apparently had a diagnosis of depression, but I agree with Dr. Anne Skomorowsky that a diagnosis of depression alone does not explain why he committed mass murder.

But if he was mentally ill, what diagnosis would best describe his condition? What do we call it when people kill other people? Is that behavior alone sufficient to say that someone is mentally ill? If so, what do we make of:

  • soldiers killing other people during war
  • gang members who, without provocation, shoot police officers or other gang members
  • suicide bombers
  • parents who kill their newborn infants because the babies aren’t the parents’ desired sex

Does a person’s intentions affect the definition of “mental illness”? (How good are we at reading the minds of others? We often assume intention when observing behavior. And those assumptions can be way off.) Does the situational context also affect what a “mental illness” is? (When in Rome, do you do as the Romans do? What if you don’t know what Romans do?)

People have surmised that people who kill other people may have conditions such as antisocial or narcissistic personality disorder. However, these designations are still problematic: Not everyone with those personality disorders kill people.

Perhaps this is why I prefer to work with people who demonstrate behaviors that undoubtedly impair their function.[2. It is easier for me to work with people who demonstrate clear evidence of “impairment in function”. Part of this is due to the greater ease and clarity in diagnosis: If someone’s symptoms are within the spectrum of normal human experience, then diagnosis is unnecessary. Part of this is also due to treatment: Some interventions in psychiatry—specifically medications—are not benign. Furthermore, it is unclear how some—many?—psychotropic medications work. We first must do no harm.] I am reluctant to describe most people as “mentally ill” because some behaviors that people find bizarre have helped the person cope with their circumstances. The people who always wear masks or scream on the street? Those behaviors may have somehow protected them in the past—even if it means that the general public derides them for being “weird”. It seems unfair to say someone is “ill” when what they have done before in the past has given them some degree of protection. (To be clear, I don’t necessarily apply this formulation to people who have committed murder. For example, I can’t think of how flying a plane into a mountain could ever be an adaptive coping skill.)

Words matter. I’m not sure that I have more clarity yet about what I should teach, though it is clear that I should focus on how I phrase the information I present.

Categories
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.