Category: Medicine

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Consult-Liaison Education Medicine Observations Reading

Hoping for Hope for Psychosis.

The American Board of Psychiatry and Neurology (ABPN) is running a pilot project: Psychiatrists and neurologists can read a set of articles and answer mini-quizzes over the course of a year instead of taking a multiple-choice exam. If the physician answers enough questions correctly in either activity, then this supports the application for board recertification.[1. To be clear, I feel frustration with the American Board of Psychiatry and Neurology and their board recertification procedures. This “read articles and take mini-quizzes” is an encouraging improvement, but there are other aspects of board recertification that give me heartburn. This is why I am also a member of the National Board of Physicians and Surgeons.]

I am enrolled in the “read articles and take mini-quizzes” pilot. One of the mandated articles is “Improving outcomes of first-episode psychosis: an overview“. One of my professional interests is psychotic disorders (e.g., conditions wherein people report hearing voices and beliefs that do not appear rooted in reality). If you share that interest, you may find this article informative, too.

Note I said “informative”, not “encouraging”. Here are a selection of statements I found notable in the article:

Psychotic disorders such as schizophrenia are common, with 23.6 million prevalent cases worldwide in 2013. One in two people living with schizophrenia does not receive care for the condition. The recovery rates… and associated disability… following a first episode of psychosis have not improved over the past seventy years under routine clinical care. Although existing psychopharmacological treatments alone can reduce some symptoms, they have little impact on the outcome of the illness.

Oof. This is the first paragraph of the article! None of the statements surprise me, but when they are all put together like that… well, it makes me wonder: “When are we going to get better at this? When will we consistently help individuals with these conditions?”

At the moment, there are no approved [prevention interventions for individuals who are clinical high risk for psychosis] that have been shown to reliably alter the long-term course of the disorder.

Sigh. This speaks to population-level data. This means that we—the individual at high risk, the family and friends of this person, and any professionals involved at the time, if we happen to meet this person—grope around as we try to minimize the risk of illness. Maybe our efforts will work for This Person, but maybe they won’t for That Person. So we continue to work and hope.

The detrimental impact of illicit substance abuse on the long-term outcome of psychosis is well known, with a dose-dependent association.

Here in Washington State, we see a lot of people with psychotic symptoms who have used or are using methamphetamine. It ruins minds. I wish people would stop smoking/snorting/injecting it.

Marijuana is legal in this state and there is some evidence that cannabidiol (CBD), a compound found in marijuana, may reduce psychotic symptoms. Delta-9-tetrahydrocannabinol (THC), also found in marijuana, can induce psychotic symptoms. This is problematic. Companies sell CBD on the internet and I have concerns about how people will run with this preliminary data.

[There is a] lack of stringent evidence for a robust effect of antipsychotics on relapse prevention in the long term….

The article summarizes evidence that suggests that antipsychotic medications may simply delay the relapse of psychotic symptoms, rather than prevent them from reappearing.

One of my early jobs was working in a geriatric adult home. My work there taught me that people with psychotic disorders can and do get better. The burdens of antipsychotic medications—paying for medications, the actual act of swallowing the pills every day, the side effects, some mild, some intense—add up. I was fortunate to work with some people to successfully reduce the doses of their antipsychotic medications and, in some cases, stop them completely! (There were also at least one instance when tapering medications was absolutely the wrong thing to do; that person ended up in the hospital. I felt terrible.)

When I reflect on that time, there were no guidelines about this. These decisions to taper medications—always with ongoing discussion and with the individual’s consent—were just an effort to “first, do no harm”. Context matters: I used as much data—from the individual, family and caregivers, and the literature—as I could find before embarking on deprescribing. Was I naive and reckless? Maybe. Was I just lucky? Maybe? Was I doing the best that I could with the information I had? I think so.

Schizophrenia features are strong predictors of poor long-term outcomes… when communicating with patients, it may be preferable to use the broader term psychosis rather than schizophrenia….

As far as I know, schizophrenia is the only psychiatric diagnosis that includes the criterion “Level of functioning… is markedly below the level achieved prior to the onset“. Even the neurocognitive disorders (dementias) don’t explicitly comment on a decline of “level of functioning”.

One wonders if the long-term outcomes in schizophrenia might be even just a little bit better if those of us who give the diagnosis of schizophrenia believed that people with this condition could get better. Do we, as a group, give this diagnosis out of resignation? And what message does that send to individuals experiencing these symptoms?

And what about that recommendation that we don’t discuss “schizophrenia” with individuals with psychotic symptoms? Indeed, for individuals presenting with “first episode psychosis”, this counsel is prudent. People with psychosis do get better. But, again, do we avoid using the term “schizophrenia” because of the connotations associated with that word? “… we don’t think you will ever get better.”

Maybe this is a circular argument: The reason why a decline in function is part of the definition of schizophrenia is because there is a decline in function in people diagnosed with schizophrenia.

But what about the people who meet all criteria for schizophrenia who get better?

The people who discern the pathophysiology of schizophrenia shall win the Noble Prize, for they will have figured out how the brain works. And perhaps, by that time, the articles about psychosis will give us all hope.

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Medicine Reflection

Answers Unknown.

The chief complaint was belly pain. He described the pain as both dull and crampy. It came and went, but bothered him the most on the same night of each week.

The notes from the primary care doctor show a thoughtful search for the underlying cause. There were comments about activity logs, blood tests, and imaging studies. Months later, it remained a mystery: He still had belly pain. The investigations did not reveal any physical causes for the aches in his abdomen.

When I asked him if he had pain anywhere now in his body, he looked at me, blinked, and then looked away. He remained mute.

The first note in the medical record was a standard template for vaccinations related to overseas travel. This international adventure would be a distant memory by the time the discomfort in his gut brought him back to the clinic.

His trip to the distant land was unhampered by children. Over ten years would pass before they were born.

I didn’t ask him about his family. I knew that they now had restraining orders against him.

The next entries in the medical record describe a different person: He no longer had concerns about belly pain. The primary care doctor in the public health clinic wrote sympathetic notes about his skin infections and paranoia. The social history noted that he was no longer in contact with his family, but did not offer any reasons why.

Physicians and nurses are trained to ask questions that are inappropriate in social settings (e.g., “Have you been passing gas?” “When was your last period?”). There are also questions that we never think to ask: We don’t believe the people under our care would ever do something so inappropriate.

Did he develop belly pain because he literally could not stomach what he was doing to his children?

Maybe I only imagined that he nodded when I asked him about spiritual distress.

Could spiritual distress look like schizophrenia?

Could guilt and shame look like schizophrenia?

Could efforts to mimic schizophrenia look like actual schizophrenia?

Could a desire for a reduced punishment look like schizophrenia?

I gave him pencil and paper. “If you’d prefer to communicate through writing instead of speech, that’s okay. I’d like to know how I may best help you.”

His fingers grasped the pencil and paper for a few minutes. He looked at the floor. He then returned the pencil and paper to me before walking away.

Categories
Lessons Medicine Nonfiction Reflection

Centered and Ostensibly Serene.

The nights from that time run together in my memory: The cuffs of my scrub pants getting caught on the heels of my clogs because my pants were sagging; stuffing dry graham crackers I stole from the nursing stations into my mouth at 4am to stay awake while writing notes; what seemed like my pager buzzing against my hip every five minutes; feeling the enormous specter of unending work overtaking me and wondering if I had any remaining skills to gird myself; recognizing the sadness and anger churning within me as I witnessed and listened to tragedies, then shoving the emotions away because there just wasn’t any time I didn’t want to cry I just needed to get through a few more notes I just wanted to sleep of the mistaken belief that if I ignored how I felt, I would be okay.

“Hey, you! You coming to talk to me?” The Big Man shouted.

“No,” I replied. “I’m going to talk with your neighbor.”

“What? But then you’re gonna talk to me, right?”

“I have two other people to talk to first, but, yes, I will talk to you after I talk with them.”

“But you’re gonna talk to me, too, right?”

“Yes.”

I had just finished introducing myself to The Patient and was asking his name when The Big Man, just three feet over and behind a reinforced steel door, started yelling at me: “You lying bitch! You said you’d talk to me!” The Big Man began pounding on the door with his big fist.

The banging reverberated throughout the entire unit. Another inmate on the other side of the unit began banging his door in protest.

I sighed and rolled my invisible eyes.

BANG BANG BANG “I’m sorry,” I said to The Patient. He nodded and came closer to his door. I did the same. “I will try to keep this short, but I do want to hear what you have to say.” BANG BANG BANG

BANG BANG BANG “It’s okay,” The Patient replied. BANG BANG BANG

BANG BANG BANG “Are you in any physical pain right now?” BANG BANG BANG

BANG BANG BANG He tilted his head, telling me without words that he couldn’t hear what I said. BANG BANG BANG

BANG BANG BANG “Are you in any physical pain?” I asked again, nearly shouting. BANG BANG BANG

BANG BANG BANG “FUCKING BITCH! YOU SAID YOU’D TALK TO ME!” The Big Man shouted. BANG BANG BANG

BANG BANG BANG “My feet,” The Patient answered, raising his voice. “I have blisters.” BANG BANG BANG

He pointed down at his feet. The puffy blisters were evidence of ill-fitting shoes. The Patient reached down, grabbed a sandal, and threw it in the direction of The Big Man. BANG BANG BANG “Stop it, man.” BANG BANG BANG I watched it sail past me and bounce in front of The Big Man’s door.

BANG BANG BANG “Do you want me to get that for you?” I asked, recognizing that the pair of sandals were now separated. BANG BANG BANG

BANG BANG BANG The Patient chuckled. “No,” he answered, a small smile on his face. “I only had one, anyway.” BANG BANG BANG

BANG BANG BANG “Do you want another pair?” BANG BANG BANG

BANG BANG BANG “YOU WANT ME TO STOP DOING THIS? THEN YOU NEED TO FUCKING TALK TO ME, BITCH!” BANG BANG BANG

BANG BANG BANG “No, I’d rather have a pair of socks,” The Patient replied. BANG BANG BANG

BANG BANG BANG “I’ll get you a pair.” BANG BANG BANG

Despite the increasing rate and volume of The Big Man’s fist hitting the door, The Patient and I both ignored him. It was clear that we had both mastered this skill at some point earlier in our lives. The Patient made it look effortless; his face was calm and his voice was even. Even though he had thrown his shoe, his limbs did not become tense again.

The Patient told me about his health, asked me to call his counselor, and, when I ended our conversation only a few minutes later due to the noise, he thanked me.

BANG BANG BANG “No, thank you,” I said, smiling. “I appreciate your patience. I will try to talk with you again later. Maybe we will have better luck.” BANG BANG BANG

I didn’t look at The Big Man as I turned away. He stopped banging when I had walked a mere ten feet away from them. I then rolled my actual eyeballs. I knew that was when he would stop.

The stress of internship and residency most certainly contributed to my current abilities to stay centered and ostensibly serene in the midst of chaos. We all had to learn how to manage ourselves in the face of death, disease, and distress. Sometimes our efforts were successful; sometimes we felt embarrassed because we believed our efforts failed.

I learned how to show myself more kindness during residency. This wasn’t a conscious choice. Three things happened:

  1. In learning how to provide psychotherapy to others, I learned how to apply these skills to my own life.
  2. I couldn’t contain the sadness and anger that churned within me as I witnessed and listened to tragedies. Sometimes I cried in the bathroom. Most of the time I wept at home.
  3. People—and more often than not, patients—demonstrated grace and kindness during these moments of heartbreak. They often exhibited a capacity to accept their circumstances and show compassion, despite their physical or psychological pain.

I felt my chest fill with grief as I walked away from The Patient and The Big Man.

What happened to The Big Man? When and how did he learn the only way to get his needs met is to destroy silence?

What happened to The Patient? When and how did he learn to show grace and respect in the midst of hateful noise?

I didn’t cry because, this time, I didn’t shove the emotions away.

Categories
Homelessness Lessons Medicine NYC Observations Reflection Seattle

The Kind of Energy We Send Out to the World.

I have been writing; I just haven’t posted anything here. These days, it seems that we cannot escape increasing types of noise and their loud volumes. It’s not all noise, but the signals are overwhelming.

It was a busy teaching week for me: I had the privilege to speak at two community clinics and a public hospital. In all three presentations I commented on the tension between “the system” and our efforts as individuals. When we’re trying to provide care and services to individuals, sometimes the constraints of “the system” interfere with our efforts: Sometimes fiscal concerns reign supreme; sometimes the bureaucracy is inflexible; sometimes the system does not have noble intentions. We grumble, we get angry, we feel helpless.

When we’re trying to design “the system” to provide care and services, sometimes the constraints of people interfere with our efforts: Sometimes there aren’t enough people; sometimes people make mistakes; sometimes people do not have noble intentions. We grumble, we get angry, we feel helpless.

The two, of course, are related: People design systems. People work within systems. People can change systems.

People also have values. Sometimes we find that our values clash with those of the systems we work and live in. That doesn’t mean that we must defer to the values of the system. It takes courage to resist. To show our values to the world without flinching is an act of bravery.

While speaking, I told a story about my first boss when I finally started working as an attending psychiatrist. Our jobs included working with people who were homeless in New York City.

“I want people who don’t have a place to live to get excellent care,” he said, perhaps talking more to himself than to me. “Good care shouldn’t be limited to people who can afford to pay a psychiatrist who works out of a plush office on Park Avenue. People who don’t have money should have access to and get good care, too.”

“These are choices under our control,” I said to the audience yesterday, perhaps talking more to myself than to them. “Even though system pressures are very real, you can choose to give good care to the people who come here for help. You can treat people with dignity and respect, particularly if they are people of color with very low incomes. They might not get dignity or respect elsewhere.”

Perhaps my exhortations sound naive. Perhaps cynicism will triumph over virtue. However, I refuse to embrace cynicism. Cynicism makes for terrible company. Life is already full of challenges; we do not need negative soundtracks to accompany us as we travel through life. What we do affects others. What we say can inspire others.

We have responsibility for the kind of energy we send out to the world.

Categories
Lessons Medicine Nonfiction Reflection

On Gratitude.

Expressers significantly underestimated how surprised recipients would be about why expressers were grateful, overestimated how awkward recipients would feel, and underestimated how positive recipients would feel.” – Undervaluing Gratitude: Expressers Misunderstand the Consequences of Showing Appreciation

The past 30 days have been unusual because of the number of professional gestures of gratitude I’ve received:

  • I received a clinical faculty award from psychiatry residents for my teaching efforts.
  • An hospital administrator contacted me in my professional capacity; she later revealed that she was a former patient of mine and thanked me for our time together.
  • A former patient contacted me to let me know that she is about to start law school, something she did not think she could ever do. She attributed her change in perspective to our time together.

These gestures are deeply meaningful to me. At a time when arguments, conflict, and discord seem to dominate our collective consciousness, how refreshing it feels to receive thanks!

As I do not work in an academic medical center, I never expected to receive a teaching award. While I do some teaching for the residency, I have limited exposure to the trainees. That the residents even thought of my name for the ballot is meaningful. In my professional role, I have the privilege of teaching topics related to psychiatry to a variety of audiences—community members, attorneys, judges, case managers, nurses, social workers. Praise from students, though, is of greater value to me than praise from judges and others who have similar social status. As one of my more precocious medical students once commented, “I should know what a good teacher is, since I’m a medical student and many people teach me….” It makes me grateful for the teachers[1. I believe that literally everyone you encounter in life is a teacher. Sometimes you don’t want to learn what they have to teach you, but that doesn’t dilute the value of the lesson. And sometimes the best teachers in our lives aren’t identified as “teachers”.] in my life who have helped me develop my teaching skills.

Similarly, it is always a delight to receive thank you notes from past patients. Even though I often cannot remember the names of people who were under my care in the past, I recall how many of them taught me how to improve my skills in listening, using plain language, and applying interventions—medications or otherwise—to improve their health. I also recall the shame, fear, and suffering that they shared with me… and how, sometimes, I screwed up and gave them reasons to distrust me in the future. Sometimes I did better. Sometimes I think I did better when, in fact, I did not.

My boss (who is not a physician) recently gave me some feedback: “Maria, you’re hard to read. I usually can’t tell how you’re reacting to something.”

I laughed. “You’re not the first person to tell me that,” I said before continuing, “Like, when I was a fellow in New York, I had supervision with an attending (a physician) and, for whatever reason, I burst into tears because I was upset. To his credit, he didn’t freak out. He, a native New Yorker, sat with me and commented in that direct way that New Yorkers are known to do, ‘I had no idea you were so upset. You should know that you don’t show any signs that you’re upset.'”

After my mom died, I have put more effort in expressing my emotions. (To be fair, though, most of the expressing happens in words, not in my face.) Most of these expressions are of affection and gratitude. It sounds dramatic, though it is true: We never know when people will leave our lives, whether from death or other reasons. As noted in the opening citation, we might not think that what we say has much impact on others. However, expressions of affection and gratitude, at least, cause no harm and, at best, are emotional gifts that strengthen social bonds and foster harmony.

There is value in expressing displeasure, too. Sometimes people need to know that we’re upset, that we feel distress with current circumstances. Though it might make us uncomfortable, expressions of displeasure can ultimately strengthen social bonds and foster harmony. Sometimes we must travel the difficult path, even if it means that we will travel alone for a bit.

I am not old, but I am also not young. I am grateful to have the opportunity to work as a psychiatrist and to teach others the little that I do know. I am grateful that you, dear reader, have made it to the end of this post. Thank you.