Category: Medicine

Categories
Homelessness Lessons Medicine Observations

Saying Good-Bye.

I originally wrote the post below over five years ago. It’s about a teenager I worked with for about six months at a residential treatment center. I still think about him from time to time; I hope that he was able to exit the mental health system.

A few months later, I learned that, less than 24 hours after we said good-bye, he injured himself while destroying property. He apparently threw chairs, punched walls, and tried to knock over bookcases and other pieces of furniture. There was no obvious trigger. It took four adults to subdue him. Staff commented that he had not behaved this way in over two years.

“That’s how he dealt with termination,” a staff psychiatrist murmured.

I’m still not sure if I agree with him.

I’m still not completely sure of the optimal way to proceed with termination.

Termination refers to the end of the therapeutic relationship between patient and physician (or, more specifically, psychiatrist). There are essentially three ways termination can occur:

  • Patient exits the relationship (patient stops attending appointments; physician fires patient; s/he dies)
  • Physician exits the relationship (s/he dies; patient fires the physician; physician disappears)
  • Patient and physician mutually agree on a final appointment date and time and complete the session

Ideally—for both parties—the last option occurs. This allows “closure”. And, no, I’m not entirely sure what comprises “closure”, but the lack of “closure” is why many break-ups suck. Think about it: Break-ups are uncommonly mutually agreed upon events; usually one party decides to unilaterally bail, resulting in negative emotions all around.

In therapy, we do not want to recreate break-ups; instead, we want to model and engage in the graceful end of effective and meaningful relationships. (Psychobabble.)

Saying good-bye is difficult. The white coat-wearing medical doctor within the psychiatrist bristles at the idea of termination; there is something about our medical training that promotes the idea (“virtue”?) of emotional distance and independence from our patients. So many things about our profession (both intentionally and unintentionally) facilitate this: Doctors wear white coats. Doctors wear gloves. Doctors ask a lot of questions, but rarely answer any. Doctors aim for objectivity and evidence.

So when we psychiatrists terminate with patients, the experience is weird and we are often surprised with how difficult it can be.

It’s never too early to initiate termination, so I had informed the adolescent male three months prior to our last appointment together that our time was drawing to a close. At the time, Andrew said nothing.

It’s not that he didn’t have anything to say about it; I had learned by this time that he heard practically everything I said, even though his behavior often purposely suggested that he was ignoring me.

A month prior to last our last appointment together, I reminded him again of my departure.

“Have you seen that Geico commercial? You know, the one with the little kid imitating a monster?” he replied.

As the days passed, he spontaneously mentioned the limited time we had together, though he tossed his remark within a smokescreen:

“I can’t believe that happened; it kinda makes me sad. You and I have three sessions left; we have to make the most of them. So I think I am going to try asking her again, maybe when she’s not so depressed, but it’s hard to tell….”

And that’s the way it had been the entire time we spent together; he would share bits of himself—often only a sentence here, another one there—at random intervals. Sometimes he would acquiesce if I asked a few questions to clarify his remark; most times, he simply changed the subject. One day, I called him on it.

“You’re really good at changing the subject when I ask you questions.”

“Yeah, I know,” he nonchalantly conceded, “I don’t like it when people care about me. It makes me feel weird.”

And when I tried to ask him more about that, he promptly commented on the weather. I smiled—sadly—at him.

The last time I saw him, he greeted me warmly.

We learn in the course of our training that therapeutic termination includes reviewing the time spent together and commenting on progress and goals attained. It’s like a summary statement, an opportunity to reflect upon how the patient has changed and how the patient can continue to effectively pursue his goals.

I already anticipated that, though he would hear my monologue of the above, he would not respond. My hypothesis bore true.

I commented on our very first meeting and what he stated were his goals at that time.

“Did I tell you the joke about the buffalo?”

I continued to commend him for the significant progress he had made in several spheres.

“What did the mother buffalo say to her kid as he left for school?”

I then reiterated his strengths—he had so many: he was so good with people; his integrity was admirable; he was intelligent and thoughtful; he was fiercely independent and more than capable of taking care of himself.

“Bi-son!”

I expressed my hope to him that he would continue to pursue his dreams—I was (and still am) confident that he could reach all of them.

“How about the one about the cowboys?”

I looked at him, willing him to participate in the conversation—but I knew saying good-bye was not his strong suit. His parents had abandoned him when he was young; there was no such thing as a “healthy” good-bye in his experience.

“Because they are too heavy to carry! HA!”

“Take care of yourself,” I said, patting his shoulder. “Good-bye, Andrew.”

He had already started to walk away when he answered, “All right.”

I watched his lanky figure amble down the hallway. I then quickly turned to go.

Categories
Education Medicine Nonfiction Observations

CPR and Informed Consent.

Radiolab recently aired a show called “The Bitter End” that discusses the end-of-life care preferences of physicians and non-physicians. Physicians are much more likely to decline “heroic” measures, such as CPR, mechanical ventilation, feeding tubes, etc. This comes as a surprise to the hosts and, presumably, to other non-physicians. It’s a good show. I recommend it. (Full disclosure: I like Radiolab.)

In the show, Ken Murray argues that physicians decline these “heroic” measures for intellectual reasons. He argues that we know the data, which includes a study that reported that, of people who receive CPR, only 8% are successfully resuscitated. (Of those 8%, only a portion of them return to their full previous function.)

I don’t think physicians decline CPR and other “heroic” measures because of evidence-based, numerical data alone.

The experience of performing CPR and attending to patients who are critically ill contribute to physician preferences against CPR. It’s emotionally taxing. All physicians have seen the trauma we cause with these “heroic” measures. Yes, performing CPR can lead to cracked ribs and punctured lungs. Mechanical ventilation can lead to severe cases of hospital-acquired pneumonia. Intravenous hydration can cause massive tissue swelling. The consequences of heroic measures are often devastating.

Physicians are taught “first, do no harm.” Sometimes, these heroic interventions seem like they cause more harm than good.

Perhaps physicians decline CPR and other “heroic” measures because of anecdotal experiences and emotions. This isn’t randomized, placebo-controlled data. However, anecdotal experiences and emotions are still data.

Furthermore, there is no true “informed consent” with CPR. When patients are able to consent to CPR, they are not truly informed. They cannot fully appreciate and understand what CPR entails because they have never experienced it.

By the time patients are truly informed about CPR—when someone is pushing on their chests, when a second person is manually inflating their lungs, when a third is injecting medications into their blood, when a fourth is trying to stick a breathing tube down their throats—they are unconscious. They cannot offer or withhold consent.

(This is true with many things in medicine: No one can give true informed consent for general anesthesia, surgery, or even medications. We often only know all the information after the fact. Patients often give consent based on hope and faith.)

Physicians see and treat patients who have undergone CPR. Those patients are usually paralyzed, swollen with fluid, and unconscious. Upon witnessing that, physicians might wonder what the differences are between “living” and “existing”.

This could explain why their end-of-life care preferences differ from that of the general public.

Categories
Education Homelessness Medicine Nonfiction NYC Observations PPOH

Daily Schedule: Homeless Outreach Team.

A sample agenda as the consulting psychiatrist with a homeless outreach team:

8:17am. Arrive at the office, which is in a tall building that is a short walk from the New York Stock Exchange. Speak with the case managers and social workers about who should be seen that day.

8:55am. Walk with a case manager to the ferry terminal meet Paul[1. All patients described here are composites of people I have seen across time.], who is a young man the outreach team has seen over the past two weeks, particularly in the early morning. Paul has said that he lives with his father in Washington Heights. When asked why people see him at the ferry terminal at night, he only repeats that he sleeps in his father’s apartment at night and walks the 10 miles to and from the ferry terminal every day. He doesn’t say much to people, but he’s often mumbling to himself. The security guards have shooed him out. He returns everyday.

He’s sitting in a chair with a ripped jacket draped over his head. Dirty sweatpants that are three sizes too big hang off of his slender frame. When he hears “good morning, outreach team” for the third time, he slowly pulls the jacket off of his head. His eyes are closed. When he hears “are you okay?” for the second time, he opens only one eye. With some prodding, he says his name, but says little else.

“I gotta go to work,” he says as he gets up. The sweatpants begin to slide down his hips. He’s not wearing any underwear. He starts to walk away and the legs of the sweatpants begin to bunch around his ankles.

“If you want, we can get you a pair of pants that will fit you better—”

He starts to walk faster and does not listen to entreaties to stop. With his left hand he grasps the waistband of his pants and walks down the escalators. He blends into the crowd of people exiting the terminal and is soon on the road outside, walking north.

“That’s Paul,” the case manager says.

“We’ll try again tomorrow.” Provide teaching on different strategies to build rapport—maybe present him with a pair of pants? a package of underwear?

9:20am. Say good-bye to the case manager and hop on a subway and head uptown, but don’t exit the station. On a bench near the rear of the station is Eleanor. She’s been homeless for over twenty years. She’s wearing two jackets and her fingernails are painted pink. No one has ever seen her nails unpainted. They always look manicured.

She’s darning socks with her wrinkled hands. Nearby is her large rolling suitcase, which is open today; inside are more jackets, several pairs of shoes, and two large bags of potato chips.

“Hello,” she says quietly. She smiles. She reports that she is fine, but her back hurts this morning. She wasn’t able to lie down last night to sleep. The security guards frequently asked her to move.

“You could move into a small apartment where security guards wouldn’t bother you. It would be your own space.”

“Oh, but I can’t,” Eleanor says. “They will exterminate me if I do that.”

She’s said this consistently over the past seven months.

“The alien transmissions—they use the satellites—tell me that I’m not allowed to move inside. They’ll exterminate me if I do. They’ll use electrocution. I don’t want to be exterminated. I can’t.”

With much coaxing, she’s actually been able to visit a housing project to see a studio apartment, but she refused to actually step into the room.

“I’ll get exterminated.”

She also declines to take any medication.

“The only medicines that work are potato chips and chocolate. Dark chocolate works better than milk chocolate. I feel better when I eat chips and chocolate.”

It’s hard to argue with that. She declines housing again today, but she’s open to another visit later on in the week.

10:00am. Get back on the subway and get off at the stop two stations away. Climb the stairs out of the station. Barry is sitting cross-legged in front of the bodega. He’s rocking back and forth while smoking a cigarette. Barry says he’s been homeless for the past eight years and the bodega owner says that Barry has been sitting out there for the past five years.

“I’m sorry,” Barry greets. A stranger leans over and leaves a deli sandwich and coffee for him. Barry mumbles, “Thanks.”

The dirt on his arms and hands indicate that he hasn’t showered in several weeks, maybe a month. Dirt is packed underneath his fingernails and bits of food are stuck in his beard. His fingertips are yellow and knobby with callouses.

“I gotta get back to work, I gotta get back to work,” he says, pointing at the building across the street. “I think my boss would give me a job again, I did good work while I was there, I did good, I did good.”

Barry also declines housing again today. “I gotta get a job first before I get an apartment. A man’s gotta work first, he’s gotta work, I gotta get back to work.”

The office receives his monthly cheques for disability (schizophrenia), but he won’t withdraw any money. His bank account has tens of thousands of dollars in it. He could afford to rent a small room, but he won’t do it. He can’t say why.

“It’s starting to get cold. If you don’t want to move inside, can I at least bring you a jacket or two?”

Barry stubs out the finished cigarette. He stops rocking.

“Yeah, sure,” he finally says.

11:00am. Team meeting. Discuss progress on different clients the team is following. Two people moved into transitional housing in the past week! One moved into permanent housing. People are excited about the individual who moved into permanent housing because he was homeless for over ten years. He often shouted at and hit himself for sins he said he committed. Despite that, everyone liked him, including the police, because he also had a sharp sense of humor. He also fed the pigeons every day.

He refused to move inside for over a year. After multiple visits to the housing project, he finally said he would give it a try. It’s been three days and he hasn’t left. Sounds like he was adjusting fairly well to his new digs, but he still sleeps on the floor.

12:00pm. Lunch. Chart the encounters in the morning.

12:45pm. A case manager brings a man to the office who is willing to sit for a psychiatric evaluation. A plastic bag hangs from the man’s hand. Inside is a brown paper bag that holds two 24-ounce cans of beer. One of them is open. He looks down at the bag.

“I won’t drink this now. Please don’t throw them away.”

He’s been homeless for four years. He was sleeping on the floor of the pizza parlor where he worked as a sweeper, but the owner was closing the business because of financial problems. He now sleeps on trains, in subway stations, sometimes in parks. He tries to avoid the shelters because people have stolen things from him.

“I know I have an alcohol problem,” he says, his eyes sad. “It wasn’t always this bad. I don’t know how to stop. Sometimes I think I will never stop, even though I hate waking up in the hospital. Life is too hard. Beer helps me feel better. ”

1:45pm. Charting that encounter. Diagnosis determines what housing he is eligible for.[2. “Diagnosis determines what housing he is eligible for.” This is an example of psychiatrist as an agent of social control.] It’s not clear if he has a “severe and persistent mental illness”. Suggest that he return in a week; the meeting can happen outside if that’s easier. No recommendations for medications right now, but harm reduction in his alcohol use would probably be helpful. He demonstrated insight, but that may not result in behavior change.

1:55pm. Case manager asks for help with a person who lives in a park. Hop into the team vehicle and drive north.

2:20pm. Arrive at the park. The client was there earlier in the day and said that he would be there, but a walk through the park shows that the client isn’t.

Three people by the picnic tables wave hello. The outreach team sees them regularly, though they are not eligible for this program. They have been drinking, but they are not grossly inebriated. They laugh as they tease us for following them around; everyone is now enveloped in the strong fragrance of fruity, sugary alcohol.

They each hold a bottle of beer that sits inside a wrinkled brown paper bag. They offer some. They aren’t offended when their offer is declined.

2:30pm. Walk around the park one more time to find the original client. He’s still not there. Children play with a ball on the lawn, multiple games of chess are in play, students read thin books on park benches, couples hold hands as they walk along the park paths, elderly women sit and watch people walk by. The three people who are drinking alcohol laugh loudly.

2:55pm. Arrive back at the office. A client is sitting in a chair by the door. He says nothing, but he looks upset.

A case manager requests consultation.

“This guy never agrees to come in,” she whispers. “Maybe you could talk with him? He’s been homeless for a long time, but finally agreed to move into an apartment about eight months ago. He was doing fine, even saw the psychiatrist there once or twice… but apparently he’s been sleeping outside for the past two days and won’t say why.”

There are introductions. The man doesn’t want to get up from his seat. He frequently looks at the door during the stilted conversation.

“How are you, Charlie?”

“Fine.”

He learns what the case manger shared. He says nothing.

“How long have you lived there?”

“A few months.”

“What’s it like?

“Noisy.”

“Anything you like about it?”

“It’s warm.”

He suddenly starts talking about the freedom of living outdoors, except the cops harass him sometimes. He also doesn’t like the kids who try to set him on fire. The zombies send them to do that. He’s tired of the zombies.

“Who are the zombies?”

“I don’t know! Stop asking me questions!”

He abruptly gets up. Everyone pauses.

Charlie wipes his mouth on his sleeve. He drops back down into his seat.

“The zombies want me to be homeless. Every day, same thing: ‘You’re a homeless motherf-cker’. Damn!”

He talks more about the zombies and his apartment.

“You wanna try going back this afternoon? We can take you there. It’s starting to get cold out. You mentioned that your apartment is warm.”

Charlie chews on his lip and snarls.

“Let’s get into the car so I can drive you back,” the case manager gently says. He says nothing, but he gets up and walks out of the office. Everyone looks at him.

“You gonna drive me back there now or what?” Charlie mumbles.

3:45pm. Go visit a local church to try again to speak to a young man. No one is certain of his name. He believes the church is his home: The pews are his beds, the altar is his kitchen. He has washed his clothes in the font of holy water. He occasionally yells “in tongues” at parishioners. When security guards have consequently escorted him out of the church, he has tried to “cast the devils out” of them. He notably avoids the church during formal services.

Inside the church, tourists and visitors speak in hushed voices as they walk through the aisles. The security guards nod hello.

The young man is seated quietly in a pew in the chapel. His eyes are closed. He doesn’t respond to whispered entreaties to go outside and talk. He keeps his eyes closed, his hands clasped, and he breathes quietly. Another security guard watches him.

4:05pm. Back at the office. Charting.

5:05pm. Depart the office and get swept into the current of people walking towards the subway stations. Automatically look for people who are homeless along the way. It’s too crowded right now; the homeless can’t find any places in there that offer peace.

Step onto a train and notice a sleeping man holding a tattered backpack to his chest. His clothes are soiled, including his three oversized coats and flimsy cap. The soles of his shoes are ripping off, showing the dingy yellow socks inside.

A lot of people get up so they don’t have to stand or sit near him. Most people don’t look at him.

I do.

Categories
Lessons Medicine Nonfiction NYC Observations Seattle

Doctor as Patient.

It had been about two years since I last saw a primary care doctor. I was still living in New York City. My initial—and only—appointment with that physician lasted nearly an hour.

The front desk clerk had a round, pale face. Behind her was a textured wall over which ran a thin sheet of quiet water. Lush leaves spilled over the brim of the planter onto the marbled countertop.

“I’ll let the doctor know you’re here,” she nearly whispered.

He was a family practice physician. He was friendly. He smiled at me. He asked me if I lived in the city. When he learned that I worked as a psychiatrist, he commented, “Wow. That’s hard work, Dr. Yang.”

It was professional courtesy to address me by that title, though it didn’t feel right to me. I looked down to mask my discomfort. My feet dangled off of the examination table.

“Do you have a private practice?”

No, I said. I worked primarily with people who were homeless.

“Oh,” he said. “That’s even harder work.”

He asked me about my medical history, then my family history. He went through the major components of a physical exam.

He told me about his work as a primary care doctor. As a physician in primary care, it was getting more difficult to stay in business. He previously worked in New Jersey, but had been practicing in New York for a few years. He didn’t think he would leave the city. He was established now.

His technician then put square stickers on my chest and the EKG machine printed out my heart rhythms. Next, I took a deep breath in and held it as another technician took a chest X-ray. And then, another technician, who apparently worked as an anesthesiologist when he was living in his native country, told me not to worry too much when he drew my blood.

“It won’t hurt at all,” he snickered.

The physician called me two weeks later. He said that everything looked fine.

My primary care appointment in Seattle was one of the first visits of the physician’s day. I walked into the medical center and looked at the directory. I must have looked perplexed. A portly man with glasses asked, “Can I help you find something?”

“I’m looking for Dr. X’s office.”

“Fifth floor.”

Dr. X wasn’t a physician in private practice. Are there even family practice doctors in private practice in Seattle? I wasn’t sure how long the appointment would be. Not long ago, I was working with primary care physicians who had appointment lengths of 20 minutes. I envied them. I only had 15 minutes with each patient. A lot could happen in those extra five minutes.

The medical assistant was wearing a plaid shirt and black high-top sneakers. I couldn’t help but think that no medical assistant would dare wear anything like that in New York.

He left me alone in the exam room and I waited. It was a cold room and the gown was thin. I hoped that my doctor wouldn’t be harried and rushed.

After the physician knocked on the door, she quickly entered and gently shut the door behind her. She was about my age. She wore a long white coat and her stethoscope was around her neck. I immediately thought of the snarky comment one of the surgery residents had made about internists when I was a medical student:

“They wear their stethoscopes like they’re dog collars.”

“Hello, Ms. Yang—Dr. Yang? Dr. Yang, right?”

“Yes,” I said. There was that professional courtesy again.

She didn’t ask me many questions. I had filled out the general health questionnaire prior to the visit; she reviewed my responses. She typed some notes on the computer while we talked.

With what seemed like some sheepishness, she provided counsel on vitamin D. Maybe she thought that I was already aware of this. Maybe she thought that she shouldn’t go on about it because I had resources to look it up myself. Maybe she didn’t want to seem condescending. I couldn’t help but think, Don’t worry about me—just do your job. I don’t follow vitamin D as closely as you do, just as you don’t follow schizophrenia as closely as I do.

She went through the major components of a physical exam. We soon were talking about her job.

“Yeah, I went to a Prestigious Residency, but it really was malignant,” she said, pushing on my abdomen. “I’m so glad that I have this job here.”

“Do you mind if I ask about any productivity requirements you might have?”

“You may not believe this, but my schedule is built so that I only have seven patients scheduled in the morning and seven in the afternoon. I can add more on, but that’s the general schedule. That gives me time to call patients, return e-mails, and spend more time with geriatric patients, since, you know, they often have a lot of health problems and need more time.”

I was silently doing the math in my head. Seven patients for an entire morning! There were days when I had seven patients scheduled in two hours!

“Yeah, I can’t imagine working like that,” she said.

She spoke quickly after she completed the exam. “If you have any questions, you can call me or send a message through the website. It was nice to meet you.”

As I was getting dressed, I found myself wondering about all the tests she could have done, but did not. Wouldn’t it have been nice if she had baseline studies for me? What if I developed an arrhythmia in the future? Wouldn’t a previous EKG be useful for that? And what about basic labs? What if my kidneys start to peter out? Wouldn’t it be nice to know that they were fine in 2012?

And then I caught myself. Most women my age are healthy and without medical problems. I hadn’t endorsed any symptoms that would warrant further intervention. Tests had their risks, too.

Doctor as patient. I considered myself lucky that I was able to leave without new diagnoses or the need to return within a few weeks.

And I remembered again what it was like to be a patient.

Categories
Education Lessons Medicine Nonfiction Observations

An Open Letter to All the Patients I Have Ever Cared For.

Originally written during my second year of residency. Now that I am an attending, I believe more than ever that patients “are our best and most effective teachers”.

Dear Patient(s),

Thank you for educating me.

Thank you for letting me shine bright lights into your eyes and place Q-tips up your nose. Thank you for not shooting me a dirty look when I ask you to lift up your pendulous breast so I can listen to your heart. Thank you for letting me ogle at your protuberant belly—whether it contains a baby, a liver tumor, or liters of fluid inside. Thank you for not experiencing an erection and for refraining from snide remarks when I examine your penis. Thank you for telling me that my speculum use is suboptimal and has caused you pain during your pelvic exam. Thank you for nearly kicking me in the face when I tap on your knees to test your reflexes. Thank you for peeing all over me after I remove your diaper.

Thank you for answering questions that, in any other context, are completely obnoxious and rude. Thank you for being honest with me when I ask if you are a prostitute, an IV drug user, or an alcoholic. Thank you for not assaulting me when I ask if you have sex with “men, women, or both”. Thank you for answering questions about hearing loss when you’re actually concerned about your chest pain. Thank you for not yelling at me in impatience when your back pain is “a ten out of ten”.

Thank you for telling me that it doesn’t seem like I am taking that symptom seriously. Thank you for not masking your facial expressions and allowing your face to contort in offense when I phrase a question or statement poorly. Thank you for saying “OW” when I do something that causes you pain. Thank you for screaming in my face for the duration of our time together after I look into your ears.

Thank you for letting me wake you up at 4:30am for the sole purpose of allowing me to examine your belly wound. Thank you for letting me wake you up at 8:30am, a mere ten minutes after you fell asleep after being up all night and writhing in agony in the ER. Thank you for asking me if I could get your a cup of water or ice chips. Thank you for reminding me that your thirst matters more to you right now than the fact that your potassium level is uncomfortably low.

Thank you for apologizing when you throw up all over yourself—not that you should, but your mindfulness in that moment illuminates a strength that you have that I don’t know that I would have in that moment. Thank you for crying in front of me. Thank you for sharing your deepest fears with me. Thank you for asking me to leave so you can spend time with your family, all of whom are devastated with your prognosis. Thank you for asking me to sit with you. Thank you for asking me to listen. Thank you for reminding me that sometimes, being present with patients is more important than writing for another antibiotic.

Thank you for answering questions that you have already answered for five other people. Thank you for not yelling at me when I ask the same question twice in the same interview. Thank you for refraining from comments like “You’re totally imcompetent” when attending physicians have brought up a diagnostic or therapeutic possibility that I had completely overlooked (or just did not know). Thank you for not spitting in my face when all I seem to say is “I don’t know”. Thank you for not throwing things at me while I nod off when the attending physician is speaking to you.

Thank you for telling me that you have thought about killing another person. Thank you for your attempts at pushing my buttons, whether it be through questioning my technical knowledge, academic status, or medical specialty. Thank you for sneering at me.

Thank you for calling me “doctor” when I don’t feel like one at all. Thank you for saying “thank you” when you’re getting better—in spite of me, not because of me. Thank you for poking fun at me for the express purpose of making me laugh. Thank you for giving me a hug before you leave the hospital. Thank you for smiling at me.

Medical school and residency training involves a lot of reading, tests, and studying. But the truth is, you are our best and most effective teachers. And for that, I thank you.

Sincerely,
Maria