Category: Medicine

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Consult-Liaison Education Informal-curriculum Lessons Medicine Observations

Informal Curriculum: Lesson 1.

It’s been over a year, but I haven’t forgotten about the Informal Curriculum.

The first recommendation in the informal curriculum in medicine, which I still believe is “paramount, the most difficult to define, and often challenging to implement”[1. It is no coincidence that a topic that is “paramount, … difficult to define, and … challenging to implement”, is also difficult to write about.] is to be a person.

What does this mean?

Be the best professional person you can be. Be a person who actively listens to patients, who shows empathy and emotions. Be courteous. Show humanity. Be a person.

Non-psychiatrist physicians seem to have an easier time with “being a person” than psychiatrists. Psychiatrists, as a population, can be weird. We can demonstrate exceptional skills at not being people. Sometimes we come across as intrusive, awkward, and odd.

I get it. I’ve had peculiar interactions with psychiatrists who knew I work as a psychiatrist. That might explain why the conversations were even more uncomfortable than expected. (Those are stories for another day.)

Do note that this recommendation exhorts you to be a professional person. This doesn’t mean that you tell your patients about your relationship or health problems, how crappy of a day you’re having, or why your political views are correct. That stuff makes you a person, too, but that doesn’t make you a professional person.

If patients are telling you things that worry them, be a person and acknowledge their worry. If they tell you something funny and it’s not inappropriate to laugh[2. Being a person does not mean that you toss clinical judgment and boundaries away. There are times when you shouldn’t smile and laugh, even if you want to. That topic is beyond the scope of this post.], smile and laugh. Talk with them like they’re people, not diseases or case studies.

Be a person.

Patients often want to share a connection with their physicians. Patients suffer and worry. They want to know that you care about their suffering or worry. That’s what actual people[3. Yes, there are anecdotes that people will share their woes with and find comfort in a computer program.] do: They care about the suffering and worry of others.

Be a person.

Why is this paramount? Why is this my first recommendation in the informal curriculum?

Because relentless forces exist in medical training and work that can transform you into a non-person.

You use words that most people don’t use. Most people don’t talk about MELD scores, Glasgow Coma Scales, or HIV classification systems. You see a lot of emotional and physical anguish. You see people who are ill. Sometimes they cry. Sometimes they scream. Sometimes you see parts of them that they will never see. Sometimes you see them die.

These are the things that can make you turn into a non-person.

So make an effort every day to be a person. If you’re not, none of the other suggestions in the informal curriculum will matter.

Categories
Education Lessons Medicine Observations Reflection

On Being a Person.

Upon looking at me, there’s no doubt about it: I am Asian.

My ethnicity occasionally becomes a topic of conversation with patients. Some immediately ask me, “Yang… that’s Chinese, right?”

Others take a different approach:

“Where are you from?”

“Where am I from?” (This is meant to clarify the question, as it can mean different things….)

“I mean, where did your family come from? What part of Asia?”

Patients with significant psychotic symptoms occasionally start conversations with me like this:

“Konnichiwa! Ichiban? Teriyaki?”

or they might say things like this:

“God has a good recipe for kim chi. Do you want to know what it is?”

For the most part, it is completely clear that these conversations arise from benign intentions: Patients are trying to make a connection.

Even if I speak English with a perfect California accent or wear clothes that blend in with the fashion of Seattle, I cannot mask that I am Asian. It is a significant part of my identity and I bring it with me wherever I go.

While in training psychiatrists are often encouraged to present oneself as a “blank slate”. This psychodynaimc argument states that the more neutral you are—in speech, attire, manner etc.—the more you can analyze the “transference”, or what reactions (emotions, thoughts, behaviors) patients have upon interacting with you. These reactions are the grist for the therapeutic mill.

We, however, can never present ourselves as blank slates. Patients—people!—notice both what we bring to an interaction and what is absent. People might have opinions about my ethnicity, my facial expressions, the tone of my voice, or the scribbles I make during the conversation. They might also have opinions if I make few utterances, maintain an expressionless face, and answer questions only with questions (as demonstrated above).

Instead of being a “blank slate”, sometimes the best thing we can do as psychiatrists is to be a person.[1. To be clear, a psychiatrist should be a professional person; this is no time for sloppiness or disregard for a patient’s wellbeing and dignity. Being the best professional person you can be is still being a person.]

If people have relationship difficulties, we can be an actual person so that the patient can learn how relationships with people can be different. If people come to treatment because they have challenging relationships with themselves, we can be an actual person so the patient can learn how these views of self affect not only them, but also other people. If people have tenuous connections with reality, we can be an actual person who provides accurate feedback about “reality” (and make very clear that we’re not trying to steal their internal organs, etc.).

Being an actual person can be scary. We might worry what people (colleagues, patients, others) think of us. However, that vulnerability and authenticity we bring as people to the clinical interaction might be the most healing and inspiring to our patients.

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Lessons Medicine Nonfiction Reflection

A Dream.

A few days before I learned what happened, I had a dream about you. When I awoke, my heart felt like a bird flapping its wings inside the cage of my ribs.

The details had vanished. Only anxiety remained.

I gasped when I learned what happened. I suddenly remembered the little details, the things that never made it into the clinical notes: You liked your coffee black. You read the Wall Street Journal. You missed driving your sports car.

Where did you kill yourself? Did you get a motel room? Were you outside? What time of day was it?

You certainly planned this. When did you make the final decision? Did you waver? Did you want to waver?

They say that there are two kinds of psychiatrists: The kind who have never had a patient commit suicide, and the kind who have had patients kill themselves.

I now belong to the second group. We all join the second group at some point.

I wish you hadn’t killed yourself.

I thank you for what you have taught me, both in life and in death.

I wish you had the peace in life that you thought was only available in death.

May peace be with you now.

Categories
Education Lessons Medicine Policy

Involuntary Commitment (VI).

Recall in the second scenario the man who was throwing his furniture out of his apartment due to concerns that someone or something was trying to take over his room. How would you apply involuntary commitment criteria here?

1. Does this person want to harm himself or someone else?

There isn’t compelling evidence that he wanted to harm himself—if anything, he suggested that his behaviors were attempts at self-preservation.

Though he never said that he wanted to harm someone else, his behavior was inadvertently putting other people in danger: He had already thrown stuff out the window, where it could have injured people on the sidewalk. He also threw a guitar in your direction, though, thankfully, it didn’t hit you.

2. How imminent is this risk of harm to self or others?

Imminent. He does not appear to be responding to direction to stop throwing things and perhaps it is only luck that the items he has thrown has not hurt anyone.

3. Are these behaviors due to a psychiatric condition?

Probably.

Given what we know about his history and the timeline of events, it seems likely that these behaviors are due to a psychiatric condition. However, these behaviors could feasibly be due to drug use or medical problems.

Related: Will hospitalization help treat the underlying psychiatric condition?

Probably. Hospitalization has historically helped this man recover from his acute symptoms.

What actually happened?

After the guitar crashed into the wall, other people—neighbors, staff—arrived. The man had retreated back into his room and continued to shout: “People don’t UNDERSTAND none of this is MINE how did this even HAPPEN why did I think it was OKAY I won’t let it happen again I won’t let it happen again—”

After tucking myself around the corner, I shooed away the neighbors; they needed to get out of there for their own safety. A social worker used her hands to mime making a phone call, her eyebrows raised as if asking a question. I nodded.

“Hey,” I said in a quiet voice[1. The next time you’re trying to lower the volume of someone else’s voice, try lowering the volume of your own voice. It’s hard to yell when the other person is barely audible.], “I’m sorry you’re feeling overwhelmed. Just so you know, though, we’re calling 911. I’m worried about you.”

He grabbed the clock off of the wall with one hand and a framed photo of his sister and him with the other and threw both out the window. Both shattered when they hit the sidewalk.

“I DON’T CARE you can do whatever the F@#$ you want I just NEED to get rid of all this SH!T—”

The rest of us waited.

Before the police and paramedics arrived, he had thrown a floor lamp, more silverware, and much of his clothing out the window. Papers were scattered on the floor. He smashed all the mirrors in his apartment. He tore the curtains from the walls. He threw several pieces of fruit, one remote control, and his pillows out into the hallway.

I braced myself as the police appeared in the hallway. Please cooperate… please cooperate… I hope the cops won’t be jerks…

The social worker had already briefed the police and paramedics about the situation.

“You Dr. Yang?” an officer asked. I nodded.

“And that’s the guy?”

“Yes.”

“We’ll take it from here. Can you write an affidavit?”[2. An affidavit is a written declaration that is used in court, in this case to hospitalize this man against his will. The police were asking me to write the affidavit because of my credential and because of my relationship with the patient. This affidavit included my opinion that he was a danger to others, given that he had thrown a guitar at me and had continuously thrown items out of his window.]

He was rummaging through his closet when the officers knocked on the door. He looked over his shoulder and paused as the officers greeted him. A few beats of silence followed.

“OH GOD WHY WON’T THEY LEAVE ME ALONE?” the man suddenly bawled. He fell to the ground and began to weep. After glancing at each other and then me, the officers and paramedics walked in.

He initially balked at their overtures about transport to the hospital, though he ultimately agreed. He choked on his sobs on the gurney as the paramedics wheeled him down the hallway.

He was in the hospital for over a month.

At our next appointment, he sat in the chair, his eyes glazed over, his body twenty pounds heavier.

“I’m sorry about what happened that day,” he said.

“That’s okay,” I murmured. “I’m glad you’re here.”

Categories
Education Homelessness Lessons Medicine NYC Policy

Involuntary Commitment (V).

Recall that the first scenario described a homeless woman who did not seem inclined to move to shelter despite the forecast of a heavy snowstorm. How would you apply involuntary commitment criteria?

1. Does this person want to harm himself or someone else?

There was no evidence at that time to suggest that she was considering suicide or homicide. One might wonder about grave disability, as her behavior in that context was not consistent with most other homeless people at that time. (Because of the pending snowstorm, most of the homeless encampments were empty that morning.)

2. How imminent is this risk of harm to self or others?

Imminent. The snowstorm had already started and six inches were forecasted to cover the ground in the next few hours. If the snowstorm occurred as predicted and she did not move, she would be at significant risk of developing hypothermia, frostbite, or complications from both.

3. Are these behaviors due to a psychiatric condition?

Maybe.

She had mentioned one thing (“The government secrets are safe with me”) that might suggest a delusion, though we don’t really know what she meant when she said that. Her behavior suggests paranoia, though it is also understandable if people don’t want to talk to strangers.

Just because someone is homeless does not automatically mean that mental illness is present, though individuals who are chronically homeless are more likely to have a mental illness. Given what we knew about her, it seemed more likely than not that she has a psychiatric condition.

Related: Will hospitalization help treat the underlying psychiatric condition?

Maybe.

If it isn’t clear if she has a psychiatric condition, then it isn’t clear if hospitalization would help.

So what actually happened?

The outreach workers working with me wanted to send her to the hospital for evaluation and treatment. I wasn’t confident that she would actually be hospitalized. If I was working in an psychiatric emergency room, I probably would have released her. Her presentation did not seem to meet a minimum threshold for dangerousness, though she did not appear well.

The snow continued to fall. No one said anything. I excused myself to step away and consider the options.

I was worried about her. She had reported that she had been homeless for decades in New York; this wasn’t the first major snowstorm to hit the area. However, she was now older and just because she survived past snowstorms did not mean that she would survive this one. Furthermore, other individuals with comparable experience with homelessness had abandoned their campsites that morning—why hadn’t she?

In New York State, two physicians are required to detain a person against her will. If I began the process in the street, the emergency room psychiatrist could either complete the process or reject my proposal and release the individual.

With reluctance, I ultimately began the process for involuntary commitment. I was not convinced that she needed hospitalization, though I knew that the process would take several hours. Hopefully, the snow storm would blow through in that time.

She wasn’t pleased when the ambulance arrived (“I’m fine… I’m fine…”), though she did not resist the paramedics. I sat in the back of the ambulance with her. She was shivering. Neither one of us said anything; what could we talk about?

“So… what do you think of this weather we’re having?”

Upon arrival at the emergency room, I gave a brief report and the commitment paperwork to the psychiatrist on duty. The psychiatrist commented that he had never seen her before, which did not surprise me: Sometimes the most vulnerable and ill individuals never interact with the health care system.

“From what you’re telling me, I don’t think we’re going to detain her,” the emergency room psychiatrist said.

“I understand.”

A guard and a nurse asked her to empty out her pockets and remove her parka. She did not balk. Though I knew she was thin, I was taken aback with just how slender her frame was.

The snowstorm blew through. Close to eight inches collected on the ground. The rare pedestrian dashed across the empty streets through the blurry grey air.

I got a phone call as the storm was ending.

“We’re not going to hospitalize her; there’s not enough.”

“That’s fine. Thanks for letting me know.”

The next time I saw her she was standing on a corner, her hands in the pockets of that same parka. When I greeted her, she turned around and walked away quickly. She spurned my greetings for nearly three months.

I understood and could not blame her.

Only after three months did she finally agree to talk with me. One brisk morning, while she was still tucked under the plastic bags filled with paper, she finally told me her story. She probably demonstrated significant psychiatric symptoms in the past (and was probably diagnosed with schizophrenia), though she experienced less symptoms now. She still didn’t want housing because she believed that she didn’t deserve housing.

I left New York and she remained. I still think about her occasionally and wonder if she is still alive.