Category: Medicine

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Consult-Liaison Education Medicine Observations

Red Herring (IV).

Five hours had passed. I was kicking myself: Maybe I should have asked that she be sent to the psychiatric side of the emergency room. It might have been quieter. Maybe she would have been evaluated sooner. If she was admitted to the psychiatric unit, then at least a medicine consultant could see her there.

But I knew that would amplify bias. This was a woman with a diagnosis of schizophrenia who had a history of self-induced vomiting. Both hospital psychiatrists and internists were susceptible to the bias that these factors were the causes of her weight loss, especially if they saw her in a psychiatric unit. I wanted her to receive a fair medical evaluation, if there was such a thing.

I also didn’t want my patient to experience a medical emergency in the psychiatric unit. Psychiatric units are the least equipped to deal with that.

The soonest appointment my patient could get with her primary care doctor was two months out. Because she was “a poor historian”, her worker accompanied her to the clinic. I told him to please call me if the internist had questions. He did: “I’m here with the patient at the doctor’s office. Dr. Checkedout wants to talk to you.”

We introduced ourselves.

“Thanks for seeing my patient. What do you think is going on?”

“She said that her teeth are bothering her, so that’s why she hasn’t been eating—”

“Wait, what? Her teeth? But—”

“Yeah, she said that she has pain in her teeth. That’s probably causing the decrease in oral intake, which is contributing—”

“Did you get the history that she has been vomiting—”

“That’s what the worker said, but the patient said that she was fine—”

I slapped the palm of my hand against my forehead.

“—and she said that her teeth hurt.”

“The patient always says she’s fine. The worker has a more detailed history and we’re concerned that something medical is causing the vomiting—”

“The patient said she’s not vomiting. Her weight is down and she knows this. She said that her teeth hurt…”

Feeling defeated and realizing that I had interrupted everything she had said thus far, I waited for her to finish.

“… and that’s probably why her weight is down. Her exam was normal. Nice woman. I asked The Worker to schedule an appointment with a dentist and to encourage her to eat more, maybe drink Ensures for now. She should come back in two or three months. By the way, I’m leaving for vacation tomorrow, so Dr. Someotherperson will be covering for me.”

Ah ha.

“Right. Can you send a copy of your note to my office?”

“Sure, sure.”

“And can you ask The Worker to call me after the appointment is done?”

“Will do.”

Ten minutes later, The Worker called me and commented, “It doesn’t sound like you were able to get through to Dr. Checkedout, either.”

“Nope. Apparently it’s just a dental problem.”

“I tried to tell her that the patient had never complained about her teeth before and that we were worried about the vomiting.”

“I know.” I trusted The Worker; he was a good man and a skilled clinician. “Well, at least Dr. Checkedout didn’t find anything alarming today. We have a follow-up appointment and we can make that dental appointment, I guess. We’ll continue to watch her.”

That was three weeks ago.

My patient had been asleep for over an hour. It was still noisy and crowded in the emergency room. I had flipped and reflipped through the two magazines.

Glancing at my watch, I realized that I had to leave to see other patients.

I grabbed a sheet of blank chart paper and copied down the contents of my typed letter. Reluctantly, I shook my patient’s shoulder. Her bleary eyes opened.

“I have to leave,” I said. She nodded. “I’m going to tie this letter to your gown. When the doctor finally sees you, make sure the doctor reads this, okay?”

She nodded and curled back up. She was soon asleep.

I wondered about HIPAA as I threaded the string of her gown through the hole punch of the paper. What if other people hovered over her and began to read the letter?

She, however, couldn’t tell the story as it needed to be told. I wished that was different.

After tying the square knot, I stood back to examine my handiwork. A nurse graciously accepted my typed letter and brought it to the clerk. After silently saying good-bye to my patient, I walked through the hallways lined with gurneys filled with suffering people and escaped the hospital.

(Part four of an ongoing series.)

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Consult-Liaison Education Lessons Medicine Observations

Red Herring (III).

In medical parlance my patient was called “a poor historian”. When this phrase appears in the chart, it means that the doctor who was conducting the interview believed that the patient could not communicate effectively. Perhaps the patient made no sense (Doctor: “Where do you hurt?” Patient: “Pain in the lettuce!”) or the patient’s report contained many contradictions (Patient with dementia at minute two: “I always take my blood pressure medicine.” Minute twelve: “I can’t remember the last time I picked up my medicines from the pharmacy.”)

In regards to my patient, she made little sense when she spoke. This, however, was not due to problems with her grammar or vocabulary.

She always said that she was fine.

She, however, was not fine.

She had lost over fifty pounds in the past year. When asked about her weight, she said that it was fine. She was vomiting on a near daily basis for the past few months. When asked about her health, she said that it was fine. When asked specifically about vomiting, she said that was fine. When asked how many times she had vomited in the past day, she said, “Three times.”

When asked to repeat what we had just spoken about, she said, “I’m fine.” Only with additional prodding was she able to parrot back the conversation.

She had huffed toluene in her former life, which destroyed many cells in her brain. We suspected this was the primary reason why she was “a poor historian”. She never seemed like she was fully present. This wasn’t willful behavior. It’s just the way she was.

For all of her problems with communication, though, some things carried over from her past: She was courteous and gracious. Whether waking up from a nap in the busy clubhouse, waiting for her worker at the office, or sitting in the lobby of her building, she’d flash a toothy grin at me and greet, “Hello! How are yoooou?” as if we had known each other for years.

Good manners go a long way.

Someone else had escorted her to the emergency room prior to her first hospitalization. We initially suspected that she had an eating disorder that led to her weight loss. During that hospitalization, however, she received two units of blood. And that doesn’t usually happen to people who vomit to lose weight.

The medical doctors abruptly discharged her from the hospital. No psychiatrist evaluated her while she was there. No follow-up medical appointments were scheduled for her. No one had an explanation for her weight loss.

Her weight only decreased further. Every week, I asked her to step on the scale in the office.

“I want my weight to be 100 pounds,” she said.

“What’s going to happen if your weight goes below 100 pounds?” I sternly asked.

“I have to go to the hospital.”

“Do you want to go to the hospital?”

“No.”

“So how much do you want to weigh?”

“130 pounds.”

She kept vomiting. Even though she continued to order fried chicken and pizza when out and sat down for meals at her residence, she continued to vomit.

“Are you making yourself throw up?”

“No.”

“When does it happen?”

“After I eat.”

“Do you have pain anywhere?”

“No.”

I had no idea how much faith to put into her answers. However, there was no incentive for her to lie, as we used her weight as the benchmark for hospitalization.

“What’s your favorite thing to eat?”

Her face blossomed into a smile.

“Cookies.”

“What kind of cookies?”

She thought about this. “Oreos.”

“I want you to eat at least half a package of Oreo cookies every day.”

She smiled even more. “Every day?”

“Every day.”

“That’s not really healthy, is it?” the patient’s worker asked. He, too, was worried about the patient’s health, though questioned the prudence of my suggestion.

“It’s not, but she needs to eat something. I just want to train her to eat something regularly.”

As far as we know, my patient never did this.

(Part three of an ongoing series.)

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Consult-Liaison Education Lessons Medicine Observations

Red Herring (II).

My patient was exhausted. She tried to drink the soup the nurses gave her, but said it tasted bad. She curled up on her right side and her eyelids drooped. I watched her fall asleep.

I wanted to talk with a doctor. Though I knew that it was unlikely she would die at that moment, I nonetheless worried that she would.

At least we were in an emergency room.

In an effort to “do something”, I brought my document to the clerks’ desk. Could you make a copy of this and put it in her medical chart?

“You have to give that to a doctor or a nurse and then they can give it to us.”

“No doctor has seen her yet and I might have to leave before she is seen. Can you please make a copy and put it in her chart? It has a lot of useful information that—”

“Listen, I can’t take that. You have to put the patient’s name and medical record number—”

“I have.” Anger made me speak louder. “I’m her psychiatrist. I have information that I want them to see. Can you please—”

“No. You have to give that to a doctor or a nurse—”

“Fine. Thank you.”

I don’t know why I thanked her. I wanted to yell at her, tell her that I was a doctor and she wasn’t. Didn’t she realize that, as a doctor, I might have some idea what the physicians would want to know? Could she only cling to a policy that made no sense in this situation?

But my condescension wouldn’t have helped my patient. So I bit my tongue and returned to her. She was still sleeping.

A voice announced over the intercom: “To help ensure that patients are seen in a timely fashion, we ask that all family members please leave the emergency room at this time.”

I did not budge. My patient would not be able to explain what had happened. I needed to speak to the doctors directly.

A security guard ambled over.

“Excuse me, miss, I have to ask you to leave.”

“My name is Dr. Yang and I am her doctor. I must speak to her physicians directly. She has not been seen yet.”

“She can talk to the physicians herself.”

“Actually, she can’t. I must speak to her physicians directly.”

“Why can’t she speak to herself? Is she mentally retarded or something?”

“No.” That’s none of your business.

“I’m sorry, but you’re—”

The security guard who saw me come in with the patient hours earlier passed by. I looked at him with hope.

“She’s fine. She can stay.”

“Thank you,” I said. Both guards walked away.

More time passed and no physicians were in sight. I began to think about quality improvement. What if hospitals implemented a system similar to that at the DMV, where you took a number and had some idea where you were in the queue? Why not build that into emergency rooms?

I knew why. Emergencies come in. People are seen out of order. And whenever staff saw the chart for my patient—“Woman with schizophrenia, weight loss in past year”—I knew that they would consider her a low priority.

Because, in many ways, she was. My patient wasn’t actively dying. She would not lose significant weight in the next few hours. Furthermore, she wasn’t making any noise. At this point, she was asleep, unperturbed by the cacophony in the emergency room. To everyone else, she was Not A Problem.

Though I wanted to believe otherwise, experience had taught me that when people saw a diagnosis of schizophrenia, they often did not take the patient’s—or my—concerns seriously.

(Part two of an ongoing series.)

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Consult-Liaison Education Lessons Medicine

Red Herring (I).

I sat in the emergency room and flipped through a magazine. I wasn’t actually reading; it was a way of distracting myself from all the noise.

Three hours had passed. No one had seen my patient yet.

The nurses, bless them, were kind to my patient. They brought her food and noticed that she was taking gigantic bites, but not swallowing any of it. The pocket of food in her cheek expanded and desperation stretched across her face.

“You don’t have to swallow it if you don’t want to,” I said, worried that she would inhale the food. “You can spit it out.”

A nurse saw us and grabbed some paper towels. “Here, spit that out. I’ll get you some soup. You look like you’re struggling to eat that.”

My patient obediently spit out the wad of food and looked relieved.

“Can you please document that in your notes?” I asked.

“Of course. I’m sorry that no one has seen her yet. Do you want another magazine?”

“No, I’m okay, thanks,” I said. She nonetheless returned a few minutes later with two magazines from last year.

Three hours earlier, I had shared a clipped account of her history to the triage nurse and she sent us to the medical side of the emergency room. I supported this decision, as I wanted my patient evaluated for medical concerns. That was the chief reason why I went with her. My patient would not be able to describe the problem. She’d say she was fine.

Upon learning that I was a doctor, the unit nurse pulled the emergency room attending physician away from a computer and asked me to talk to her. I immediately launched into my patter, summarizing why we were there.

I saw it happen and almost wanted to laugh: Her features hardened. The muscles that allowed any possible soft expression on her face tensed up. Her face showed nothing but muted anger.

“I don’t even know if I will see her. I’m going to go away now,” she said at me. As she was walking away, I heard her mutter, “Why didn’t she go to psych?”

During my entire time in the emergency room, she never came near us again.

My patient did not want to go to the emergency room.

“But we have to,” I said, trying to sound calm. I wished I didn’t feel as frantic as I did.

“I don’t want to go,” she said, literally hopping from one foot to another. She wrung her thin fingers together and fear overwhelmed her face. Those sunken temples seemed to sink further as she frowned.

“I know you don’t want to go, but we have to,” I said, pointing at the scale. “I said that you would have to go to the emergency room if your weight dropped below 100 pounds. Remember?”

“Yeah.”

“What is your weight today?”

“99 pounds.”

“And what did I say would happen if your weight dropped below 100 pounds?”

“I’d have to go to the hospital.”

“That’s why we’re going to the hospital.”

“But I don’t want to go to the hospital.”

“We’re going to the hospital. I’m coming with you.”

We sat next to each other in the back of the car.

“You’re coming with me, right?” she asked, her eyes looking abnormally large in her head.

“Yes. I am going to be with you until a doctor sees you. I want to talk to the doctors directly, too.”

I had written up a document that summarized pertinent information about her: name, birthdate, diagnoses, medications. I wrote down the details about how her weight had fluctuated over the past year, how she went to a different hospital just six months prior for the same reason. I wrote how she had needed two blood transfusions, how they had dropped a camera down her esophagus to look around for disease. Except for mild inflammation, everything was normal. I wrote that I had reduced her psychiatric medications; she didn’t need to take so many. I wrote that she was fine, that her psychiatric symptoms hadn’t changed in months. I shared my fears that her symptoms were due to medical reasons. I didn’t want the hospital staff to follow the red herring that was her psychiatric diagnosis.

Back in the emergency room, the nurse had asked her to take off only her shirt and put on the hospital gown. My patient peeled everything off with no shame. As she pulled herself onto the gurney, everyone saw her gaunt buttocks through the gown flap.

The hours passed. The emergency room was busy. More gurneys were pushed into the room and people were muttering, screaming, upset.

She looked at me. I smiled with my lips, but not my eyes. We continued to wait.

Part one of an ongoing series. Read more for

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Education Homelessness Informal-curriculum Lessons Medicine NYC Observations Policy PPOH

Supervision and Support.

To conclude a description of my previous job at PPOH in New York, let me tell you about Friday afternoons.

Every Friday afternoon, the staff psychiatrists met as a group for three hours.

Those three hours were important and valuable. During that time, a variety of activities occurred:

Case presentations. Different psychiatrists presented cases to solicit ideas and help. Hearing the thoughts of others provided fresh perspectives and helped us “think outside of the box”. Each psychiatrist had his specific strengths and this forum allowed us to access his expertise.

Example: Someone once presented a case about a woman who was refusing to accept treatment for a major medical problem. The psychiatrist had assessed her decisional capacity and it appeared intact. This meant that we—other doctors, her psychiatrist, other non-medical staff members—had to respect her wishes… and also watch her become more ill and eventually die. The psychiatrist who presented this case wanted to (1) ensure that his assessment of her decisional capacity was thorough, (2) learn how to manage the (often angry and frustrated) reactions of the other physicians and non-medical staff, (3) get ideas about how to coach the other physicians involved in the patient’s care when they wanted to do something and she refused, and (4) vent and get support from us, as managing his own reactions and the reactions of others was taxing.

Sometimes the case presentations were less complicated: How can I encourage this patient to try medication? Is there anything I can do to get this patient to stop asking for medication? Do you have any ideas as to how we can keep this guy out of the hospital?

Grand Rounds. Grand rounds refers to a lecture on a specific medical topic. It is often considered a “big event” (i.e. lots of people are invited or expected to go). In academic medical centers, someone well-known in the subject usually gives the lecture.

PPOH established a Grand Rounds committee[1. The PPOH Grand Rounds committee was comprised of two people: a senior PPOH psychiatrist and me, as we were both interested in medical education. If you would like me to speak at your Grand Rounds or provide other teaching, let me know.] to organize a series related to homelessness and mental health. Speakers with expertise on schizophrenia, common infections in the homeless, harm reduction, housing first, tobacco use and cessation, and other topics shared their knowledge with us.

These lectures were an essential part of continuing medical education. We need and want to learn so we can provide excellent care for our patients, particularly since there is a dearth of literature for this population.

Peer supervision/support. Every job has its challenges. In psychiatry, it is no different. Working with individuals who have significant mental health problems, homeless or not, can be stressful. Sometimes we feel anger towards patients. Sometimes we feel frustration with other psychiatrists or physicians. Sometimes we feel scared that we did something wrong. Sometimes we worry that our patients will die.

Much of psychiatric training uses the apprenticeship model. While in residency, we meet with “supervisors” (attending psychiatrists) on a regular basis. Supervisors provide coaching and guidance to help residents learn psychotherapy and prescribing practices. This is also where the informal curriculum is taught: Supervisors are essential in teaching (demonstrating) professionalism and attitudes. It is during supervision that we also learn to examine our own reactions to clinical encounters… and, oftentimes, our reactions tell us more about ourselves than about our patients.

I was deeply grateful for these weekly three-hour meetings. (I have since realized that this set-up is rare. No money is gained while physicians are meeting for supervision. Neither patients nor insurance companies are billed. From a financial standpoint, it is wasted time. However, I’d like to think that this investment in physicians ultimately provides benefits for patients. I don’t know if there is any data to support this, though I believe it is absolutely true.) The built-in network of peers gave me security: I knew I could trust them to help me become a better doctor.

Many medical students and residents feel embarrassed to ask questions. They might feel ashamed to say “I don’t know”. With time and experience, that shame goes away. It’s okay if you don’t know. What you do next is what matters: If you need help, ask for it. You will (re)learn something, you will take better care of your patients, and you can then help another doctor in the future.