Category: Medicine

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Consult-Liaison COVID-19 Education Medicine

Vulnerability and Resilience.

We had our medical staff meeting on Friday, which was the first time we had all convened since the COVID-19 epidemic was announced in Seattle-King County.

I shared with the team the following framework, which is from a paper about demoralization.[1. It is common for other medical specialties to request a psychiatric consult for a patient who seems depressed. Consultation psychiatrists often learn that it is demoralization, not depression, that results in consult requests. (Though demoralization and depression share features, most psychiatrists agree that they are distinct conditions. These distinctions are discussed further in the paper.)]

The authors note that:

Demoralization refers to the “various degrees of helplessness, hopelessness, confusion, and subjective incompetence” that people feel when sensing that they are failing their own or others’ expectations for coping with life’s adversities. Rather than coping, they struggle to survive.

and later comment that “[a]cknowledging suffering and restoring dignity are potent in strengthening a patient’s resilience to stress.”

This is the valuable table from the paper:

During this extraordinary time of the COVID-19 pandemic, this framework may help you, whether you work in medicine or not. Sometimes the act of putting words to our emotions can alleviate our discomfort and help us feel more empowered.

We may all feel overwhelmed with the emotions and experiences on the left side of the table. Many, if not all, of us during the past few weeks have felt confused, helpless, and resentful. We have felt lonely and isolated, though we may recognize that we’re lonely and isolated all together. Sometimes fear gets the best of us and we wonder if anything we do matters. Vulnerability is often an uncomfortable position.

Remember that there are things we can all do to nudge us over to the right side of the table. Thanking others helps us reconnects us with people. Looking for the helpers can inspire us and give us hope. Taking a breath (or two or three) and slowing down helps us pursue clarity so we can find the signal in the midst of all the noise. The choices we make in each moment can help us recognize and cultivate our own courage and resilience. How we choose to react to what’s happening around us can shape our purpose. Do we react in anger or kindness? Do we have faith that we will do the best that we can in face of uncertainty, or do we assume the worst in others and ourselves?

To those of you who work in emergency departments and hospitals, regardless of your role, we thank you for your courage and efforts. We in outpatient settings are doing our best to keep people healthy and out of EDs. We all look forward to the time when this will be just a memory.

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Homelessness Medicine Nonfiction Policy Seattle Systems

More Reflections about COVID-19 from Seattle.

This is another unpolished post. Several physicians and nurses in other states have reached out to ask for suggestions and perspectives related to behavioral health and homelessness during this COVID-19 epidemic in Seattle. Here are some reflections:

Coordination with partners is not only essential for services, but also to maintain morale. No single agency is able to address this alone. Government partners need feedback and information about what the community needs (and, I’m sorry to say, sometimes the community ends up providing government officials with updates that government should be telling us). The actions and energy of partners can buoy others when it seems things are stuck.

There aren’t enough supplies. Clinics, hospitals, and agencies can’t get face masks, hand sanitizer, and other sanitation supplies. Vendors are all sold out. Local governments are appealing to the federal government to provide supplies; I understand that the US military protects a national stockpile of such items? Which is something I had never considered in the past. And, perhaps most importantly, there aren’t enough COVID-19 tests! It seems that most of our local publicly funded primary care clinics have, at most, 30 test kits on site with no replenishment coming. Some private labs are only now agreeing to provide COVID-19 testing.

Many employees don’t have enough paid time off accrued to take time off of work for self-quarantine. Thankfully, our state and federal governments have passed or will pass legislation to address this and ensure that people can still get paid despite having to take time off of work. HR departments everywhere would do well to look out for their employees, particularly those who provide direct service to people who are higher risk of experiencing illness due to COVID-19.

People may (or may not) bristle at the infringement of civil liberties. The Washington State Governor has banned gatherings of more than 250 people. The CDC has provided “mitigation strategies” specific to Seattle-King County for the next 30 days, some of which are about workplace behaviors and COVID-19, which includes checking temperatures for fever and screening for illness when employees show up to work. The CDC has also recommended prohibiting visitors to certain sites. These are extraordinary times, hence these extraordinary measures… and some people may bristle at having to follow these rules. So far, people have been voluntarily complying with these changes.

The balance of individual patient health information and public health wobbles. For the past two weeks, a local clinic and our shelter have gone back and forth (in a collegial way) about protecting an individual’s privacy versus protecting the health of other people staying in the shelter. In short, the clinic argued that if Mr. Doe, a person who stays in the shelter, gets tested for COVID-19, the shelter isn’t entitled to know (a) that the test occurred and (b) the test results. We have countered that the shelter should know about Mr. Doe’s testing and the results during this extraordinary time because we want to do everything we can to prevent or minimize a localized outbreak within our shelter. Thankfully, the State Attorney General issued guidance that sided with our view (to be clear, the clinic was sympathetic to our view and did not balk with the change in practice… and I completely understood where the clinic was coming from). However, this is something that the clinic and our shelter had to pursue on our own; this was not proactive guidance we received from our government officials.

Government bureaucracy is in full effect. In this instance, I’m referring to practice of government officials who are unwilling to send out official communication until numerous gatekeepers have vetted it. Thus, guidance is slow to come out, so everything slows down. I understand the reason for vetting—confusion isn’t helpful, either—but we also feel frustrated when we feel like we’re losing a race against an invisible enemy.

People staying in shelters are resilient. Many staff feel anxious about how COVID-19 will impact the people who stay in shelters and receive clinical services from us. I find that I have to remind myself that many of the people who stay in shelters have experienced traumas and horrors that we will never know or understand. Many of them have already experienced illnesses and pain that we cannot fathom. I do not mean to minimize the very real possibility that some of them, should they contract COVID-19, will develop severe illness and die. I don’t want that to happen, which is why we are in constant communication with our partners to coordinate services and care. However, many of them will either not get sick, or they will recover despite our anxiety and efforts. It is a privilege that these individuals even let us into their lives.

Screening guidelines for COVID-19 are mushy. Some of our local infectious disease experts have taken to crafting their own screening guidelines because they are dissatisfied with the vague guidelines from the CDC. (This ties back to the lack of available tests—if we had more COVID-19 test kits, then we wouldn’t be wringing our collective hands about screening guidelines, particularly for vulnerable populations like people staying in shelters, which, no kidding, includes a significant proportion of people who are over the age of 60.)

The workforce shortage seems like it will only get worse. Social service and health care agencies often struggle with having a sufficient number of staff to address the clinical need. As people call out due to illness, whether COVID-19 or otherwise, this will turn into a vicious cycle: Fewer staff for a constant or growing need means that those staff will get tired and sick, which increases the likelihood that they will call out, and if the return to work rate doesn’t match the “attrition” rate, then soon there will be only minimum staffing at best. We also cannot expect individual people to successfully address systemic problems. It is not uncommon for people who go into social and health services to overwork (whether in quantity, quality, or both); this is unsustainable during usual times, let alone during an epidemic.

Social distancing seems like it will have the highest yield. The Institute for Disease Modeling published a paper specific to King and Snohomish Counties (the “epicenter” of the outbreak in the US) about the importance of social distancing. It is both compelling and disturbing. I don’t know how to successfully balance this with the clinical services that the medical team provides to the agency. Telehealth options are limited because of the population we serve (i.e., they generally don’t have telephones), though we plan to implement some creative ideas to at least try to keep people out of emergency departments.

It’s a weird time. We continue to do the best that we can, while recognizing that what comes next may knock us off our feet.

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Medicine Nonfiction Reflection

Clinical Training and Butt-Grabbing.

Under duress, we do not rise to our expectations. We fall to our level of training. (Bruce Lee… supposedly)

When I was looking for My Patient, well before his neighbor grabbed my butt, I remember noticing that most of the slots in the doors of the isolation jail cells were open. These slots are tall enough to pass a softball and wide enough to pass a clipboard. They are about three feet up from the ground. The slots function like small doors: The hinges are on the bottom, so the slot doors fall open when unlocked. Only people on the outside—-correctional officers—-can unlock and open the slots. The slot doors automatically lock when closed shut.

The slot in My Patient’s door was open, as was the slot for his neighbor. Before I started talking to My Patient, I remember thinking, “Maybe I should completely shut his neighbor’s slot.” I shrugged that thought away: I had been working in the jail for over five years and nothing had happened to me before. I partially closed the neighbor’s slot in a vain effort to provide some privacy to My Patient. While standing between the two doors, I leaned over to talk to My Patient, who I was meeting for the first time, through his slot.

My Patient, calm and civil, had spoken with me for only a few minutes when I felt fingers grab a handful of my gluteal flesh. In less than one second my mind had deduced what had happened: My Patient’s neighbor, who I did not know, had pushed open his slot door, reached out, and grabbed my butt, which was covered in a white medical coat. Before I reacted, he also cackled with spite, “Shake that Chinese ass!”

There are many ways I could have reacted:

  • Scream.
  • Yell, “Don’t touch me!”
  • Shout, “What are you doing?!
  • Holler, “What is wrong with you?”
  • Exclaim other combinations of profane and proper words to express my displeasure.

But what did I actually do?

“EXCUSE YOU!” I exclaimed as I whirled around. I caught a glimpse of his face as I slammed his slot door shut.

I still laugh at my reflexive reaction. There was no thinking involved. Nonetheless, my non-thinking brain still generated the phrase, of all the possible responses that are applicable in this situation, “Excuse you!” The emphasis on professionalism in training and in practice had prepared me for this day.

(Of course, the more emphatic point was slamming the slot door shut. The importance of boundaries was reinforced in training and in practice.)

I then took a breath, turned back to My Patient, and said, “I’m sorry about that. You were saying?” He resumed talking. We both pretended like nothing happened.

Though no one witnessed this event, my colleagues believed me. (Let’s be clear, though: The differences in social status alone—-physician versus jail inmate—-tipped the scales heavily in my favor.) This was the first time I had ever experienced a stranger grabbing my butt. I had announced my resignation from my position in the jail (and an administrative role in county government) just a week prior, so my colleagues, after offering support, quipped that of course this was ordained to happen.

What this event highlighted to me, though, was the respect most men show to most women most of the time, whether in or out of jail. While it is entirely possible that men everywhere are exerting great, continuous restraint from reaching out and grabbing the butts of women, I don’t get the impression that such self-control is exhausting their energy reserves. In my five years working in jail with individuals who are often demonstrating significant behavioral disturbances, this was the only time someone grabbed my butt. This suggests to me that most men—-even men in stressful conditions like jail—-have intact impulse control or are least willing to adhere to social norms about butt-grabbing.

To be clear, though: I hope I never encounter this man ever again. (And, as of this writing, he is still in jail. I got out; he’s still waiting.)

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Medicine Nonfiction Observations Reflection

Work Spouses and Mentors.

I recently had dinner with a good friend. He and I trained together at the same time and he has since gone on to become a super fancy academic psychologist on the East Coast. Over dinner, he opined that an optimal work situation includes two components: a “work spouse”, and a mentor.

“The work spouse is at the same level as you—same training, same work,” he said between bites of lasagna. “And a mentor is a mentor.”

“Yes!” I exclaimed. My mind recalled the respect and affection I had for all of my “work spouses” over the years:

  • Chris and Sohan both made me laugh, helped me with the endless scutwork to get me out of the hospital, and helped me keep things in perspective when we were interns.
  • Ryan, Scott, and Ryan also made me laugh, provided thoughtful clinical consultation, and gave sage personal advice while we became less human during residency. There was even that time when we were all on call on the same night, but at different sites… and we called each other sometime between 3am and 4am just to check in. Ryan and Scott also taught me how to throw a football; the other Ryan taught me how to improve my storytelling.
  • Sharon made me laugh during fellowship (do we see a theme here?) and provided an international perspective about community psychiatry. Sharon and her husband also invited me to experience a Passover Seder.
  • Joe made me laugh (…) and helped me cope with the stress and discomfort of 15-minute medication appointments. He also validated my opinion that such a model neither matched my values nor allowed me to provide the care that I believe people deserve.
  • Craig also made me laugh, helped me think through difficult clinical quandaries, and also validated the privileges and challenges associated with working in a jail.

In two cases I didn’t have a “work spouse”. They were both medical director positions… and in both instances I was the only physician who worked in those parts of the organizations. Let me be the not-first to say that, yes, doctors think about and approach things differently. Sometimes it’s useful; sometimes it annoys the heck out of everyone else. It’s often isolating: On the one hand, sometimes people elevate an opinion simply because it comes from a doctor; on the other hand, sometimes people disregard an opinion because the doctor’s perspective seems irrelevant. Both reactions are problematic.

“I haven’t had a mentor in years,” I said after a long pause. “Maybe that’s because there aren’t a lot of Asian women who work in public sector psychiatry?”

That might be true, but I don’t know that for sure (though, as I have progressed in my career, it seems that there are few psychiatrists who choose to work in public sector, non-hospital, non-clinic settings). My mind ran through the people I have considered mentors:

  • Randall, a gastroenterologist, taught me in medical school how to remember that patients are people.
  • James, a psychiatrist, highlighted the intellectual rewards of psychiatry and is arguably the person who persuaded me to pursue a career in psychiatry instead of internal medicine.
  • Matthew, an infection disease physician who longtime readers recognize at the Special Attending, demonstrated the intellect, kindness, and humanity that we want our doctors to possess. He was one of the few attendings I worked with who brought cold water and warm blankets to patients when they requested them.
  • Dick, a pharmacist, not only knew a ton about medications, but also dispensed Taoist wisdom about how to manage people in distress… including ourselves.
  • Deb, a psychiatry residency program director, demonstrated a steady grace and cool serenity despite the tumult of resident distress. I still recall and admire her steady support and faith.
  • Brad, a psychiatrist, taught me that “patients are called patients because they are patient with us” and that, while we have the privilege of helping people, we should discard any “rescue fantasies”. The true heroes are the patients, not us.
  • Sarah, a psychiatrist who worked as a medical director for a major US city, validated my interest in working at the boundaries of fields and also encouraged me to apply for positions that I thought were out of my league. “If something scares you, you should do it.”
  • Van, the only boss I’ve had who is both a psychiatrist an a person of color, continues to provide sage career advice and said that words, “Everyone should receive high quality psychiatric care, whether they go to a nice office on Park Avenue or if they sleep on a bench.” Just knowing that someone else thinks that makes me feel less lonely.

At the risk of sounding woo-woo, though, we can all find mentorship everyday. Everyone can be our teachers if we are willing to be students. I think about the bus driver who greets everyone with a warm smile, but has no qualms about commanding—firmly, but politely—a rider to stop harassing vulnerable people who are also on the bus. Consider the finance officer with no formal authority who speaks up during a meeting to advocate for more transparency in fiscal affairs. What about that coworker who picks up the litter in the lobby when he thinks no one is watching? Because he wants to leave a place looking better than it did when he walked in?

If you are fortunate to have a work spouse, bring him or her a treat. If you don’t think you have a mentor, remember that there are others who can provide guidance and inspiration.

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Medicine Systems

Balloons.

I worked with someone (not a physician, but that doesn’t really matter here) whose title was “assistant director”. He and I quickly recognized that we worked well together: His head brimmed with big visions and ideas, whereas my head brimmed with plans as to how to make those ideas manifest in the actual world.

“He’s like a bunch of balloons,” I quipped to a colleague. “He’s got a ton of ideas—shiny, bright balloons—but he needs someone to hold all the ribbons to keep them from floating away.”

“Do you think medical school trains us to become managers or leaders?” my colleague asked. Someone several rungs up on the organizational chart had convened a supervisor training; one of the major points of discussion surrounded the differences between “managers” and “leaders”. One suggested generated a lot of wondrous “ooooh”ing: Managers ensure that the ship is running properly; leaders ensure that the ship is going the right direction.

“Managers,” I responded. “Particularly once you get to internship.” Interns are learning on the job how to diagnose and treat medical problems in actual human beings with all the complicating factors of life: Pregnancy, poverty, rare diseases, under- or over-involved family members, a health care system that can prioritize profits over patients.

“Really? I think medicine teaches us to become leaders. By the time we are attendings, we have to hold the entire context of a specific person in mind while ensuring that junior staff learn skills—the technical stuff in addition to the bedside manner stuff—that do not result in harm to patients.”

“Yeah, I agree with that,” I said after a pause. Only upon further reflection I was able to articulate that physicians are often “stuck” as managers because we are often too busy doing clinical work to exert influence and demonstrate leadership on the systems in which we work.

Sometimes it is the system that gets in the way of us doing all the things we want and should do.

Though I am more likely to be the person holding the balloons than the actual balloons, Big Thoughts still trickle through my mind:

  • What if the public mental health and substance use disorder systems worked from the assumption that people will get better and no longer need services? What if we built a system where people didn’t get stuck in it?
  • What if the ratio of “case management” to “treatment” was flipped in the public mental health and substance use disorder systems? What if people received effective treatment sooner? Would people then need as much “case management”?[1. To be clear, case management is important. The public systems are complicated and confusing. Case managers can help people navigate their way through and hopefully out.]
  • What if various skills—emotion regulation, distress tolerance, effective communication, relating to others, self-reflection—were automatically included in prenatal care and continued post-partum?
  • What if various skills—emotion regulation, distress tolerance, effective communication, relating to others, self-reflection—were included in school curricula for every grade?
  • What if designated leaders and managers of clinics, hospitals, and other health care entities included more clinicians (of all stripes) and people who receive services there? What if it were routine for health care entities and regulators—particularly Medicaid and Medicare—to solicit and implement ideas from clinicians and people who receive services?

I agree that systems—whether formal or not—need both managers and leaders. I also agree that the most effective managers and leaders do not rely upon their hierarchical positions to promote change and improvement; they instead cultivate and nurture interdependent relationships throughout the system. After all, in health care, our primary goal is (or at least should be) to help others.