Category: Nonfiction

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Education Lessons Nonfiction Policy Reflection Systems

What I Learned in Government.

It’s been nearly four months since I posted something here. Don’t be fooled: The lack of words here did not mean an absence of word salads tossing about in my head.

I recently resigned from my job. (All The Things related to that contributed to my silence here.) My job had two parts: One involved administrative work as the behavioral health medical director for local government; the other involved direct clinical service in a jail. I was in that job for over five years. It took me about two and a half years to figure out what an administrative medical director does. (As the process of becoming a doctor involves frequently feeling incompetent, this discomfort wasn’t new to me.) Now that I’m on the other side of this job, here’s what I’ve learned:

I believe government can do good things. You know that stereotype that government employees are lazy? I did not find that to be true. Every organization has a proportion of staff who do not seem motivated or interested. The proportion, in my experience, does not seem higher in government. If anything, many of my colleagues came to government with eager hopes of improving the community. They came in early, stayed late, and worked on weekends. They convened groups with opposing viewpoints, advocated for different populations in the region, and expressed dissent to people in power. They sought out and willingly worked on complicated problems. They demonstrated the humility that comes with the realization that tax payers are funding their salaries.

I do not enjoy the game of politics. Some people love it! They enjoy the contests of status, flaunting their connections, and attacking perceived enemies in public forums with the brightest of smiles. Sometimes people asked me to speak, not because they cared about the content of my words, but because of my credential as a physician. (“Let’s trot out The Doctor.”) I grumbled about “perception management”; often it seemed that the surface sheen mattered more than the substance underneath. (On the other hand, it is likely that my glittery MD credential is what allowed me to say to superiors that poop will never develop a patina. It is unfair that systems often value specific people more simply because of the letters after their names.)

Government work has made me both more and less patient. It takes time to elicit ideas and information from “stakeholders”, community members, and others. People want to and should be involved if a policy or program will impact their lives. They share perspectives that government never thought to consider. I respect that process. I am less patient with the nonsense people and systems can generate to subvert fair processes. Some people are more prone than others to misuse power. That’s hard to watch in a system like government, which has access to and authority over so much money… and, in our current system, whoever has more money almost always has more power.

I learned a lot about laws and regulations. I came to appreciate the value of regulations, though they tend to address the lowest common denominator. Government spends most of its time aiming low to define the floor instead of inspiring people to elevate the ceiling. (I wrote more about this here.)

Government administrators forget what happens in direct service. Though many people in government once provided “front line” services—as attorneys, social workers, counselors, activists, whatever—many of them seem to forget the challenges of systems that are intended to help people. This includes the thousand little cuts of too much paperwork and the major crises of people dying due to missing or underfunded services. My opinion that all medical directors should routinely provide direct clinical service has only gotten stronger with this experience. Someone has to inform the others at The Table what’s going on outside.

Systems are made of people. Contemporary discourse often focuses on systems, not people… but people make up systems (i.e., individuals create, operate, and maintain systems). As such, single individuals can still have significant impacts on systems. This includes grinding things to a halt… or breathing life into new programs. (This is where political gamesmanship can be useful.) The hierarchical organizational chart can lead people who are “lower” to think that their efforts don’t matter, but that’s simply untrue. Systems can change because people can change… whether that’s because people actually change their ideas and behavior or people in certain positions leave.

I am deeply grateful for the opportunity to work in government. I never thought I would work as a civil servant (and, in fact, there was a time when I said I’d never work for government… which is why I’ve stopped making five-year plans). If for nothing else, now that I’ve been on the inside, I can use that experience and knowledge on the outside.

The outside suits me better. So it’s time to go back.

Categories
Medicine Nonfiction Seattle

Questions After a Suicide.

To my knowledge, three people who were under my care killed themselves.[1. Additionally, three people who were active patients of mine tried to kill themselves. Then there are the people who have killed themselves, and I am simply unaware that they have died from suicide.]

The first was a young man—late 20s, maybe?—who I met while I was a psychiatry intern. He was hospitalized in the psychiatric unit where I had just started my rotation. I did not have the opportunity to get to know him well. Our paths crossed, at most, for two days. He had a diagnosis of schizophrenia. I can conjure up his face in my mind, though I do not remember his name. He didn’t blink much. While his face did not betray fear, he often looked uncomfortable.

I don’t know how many days he had been out of the hospital before he died, though I think it was within a week of his discharge. He jumped off of the Aurora Bridge (before a suicide prevention fence was installed) into Lake Union in Seattle.

The second was a man in his late 40s who had repeated visits to a crisis center. He did well in college and earned a law degree. His career as a lawyer was cut short due to problems with depression and alcohol. From there he became homeless and destitute. He had a diagnosis of major depression. Some professionals thought he had a personality disorder.

He was smart and sarcastic. While he was often critical of everyone around him, there were moments when he was self-effacing. After we had worked together for a few months, he commented that he liked “debating” with me, though I suspected that arguing was the only way he knew how to interact with other people. On the rare occasions when he took a break from his self-loathing, he considered how his life could change. He didn’t drink as much alcohol now as he once had, but it still helped him forget his shame and regret.

When I learned that he had died from an overdose of methadone, I knew immediately that he had intentionally killed himself. He had no history of using opiates, but he knew how, with or without alcohol, they could end his life. Over a month had passed between our last conversation and his suicide. When I learned of his death, I asked him—as if he could hear me—why he didn’t come back to the crisis center. He knew that he could.

I have not forgotten his name. Earlier this week, I saw his name in a newspaper. It wasn’t him, of course; the name belonged to an author who was promoting his book. I hadn’t seen this name elsewhere before. It made me wonder if my patient was saying hello.

This past week, I learned that a third person who was under my care killed himself. He was in his 20s, smart, and funny. When his symptoms were active, he was very ill. In the minutes to hours leading up to his death, was he experiencing a resurgence of his symptoms? Or was he mulling over how his illness could impact his life in the future and decided to impact his life first?

The last time I spoke with him, we talked about how his condition did not define him. His identity wasn’t solely his illness. We talked about the things he wanted to do in the future and how he could accomplish those things.

The person who called me to tell me the news heard my breath catch in my throat.

Death, while uncomplicated in some ways—it’s a permanent cessation of all vital functions, the end of life—our attachments make it complicated in other ways. We have so many questions that will forever go unanswered. We wonder where the dead go. Does a part of them persist outside of our memories? And for those who kill themselves, what happened? What got in the way of them asking for help? What made death the best option? What made them believe that the rest of us could not or would not understand?

The end of a life never just impacts the individual who died. The ripples spread far and wide. We search for words to describe our grief, but language fails us.

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Medicine Nonfiction

Follow Up.

To my surprise, he called my name and asked to talk with me.

I didn’t bring up the incident that had occurred the last time we spoke: He got upset because he believed that I had put voices into his head. I wanted him to associate me with attributes other than hallucinations. There was no way I could help him if he believed that I was doing things against his wishes.

“So, hey,” he volunteered after we had spoken for a few minutes, “I’m sorry for yelling at you the other day. I was already thinking about robots and when you asked me about them, I freaked out. I’m sorry.” A sheepish smile bloomed on his face, but his eye contact did not waver. He looked and sounded sincere.

“It’s okay,” I replied. “This is a stressful situation and sometimes we all get upset over things that we feel like we can’t control.”

He nodded. We talked about the voices—they were still talking to him, but they were quieter now—and what other things he could do so they wouldn’t bother him as much.

Even though I’ve been doing this work for years now, there are still moments when I am astonished with the effectiveness of medications for symptoms of psychosis. I already knew they can save lives. I already knew they can transform lives. And yet!

“I am going to ask the nurses to offer you medicine,” I said the last time we met while he was yelling at me. “You don’t have to take it, but I think it will help.”

And, for whatever personal reasons he had, he took it. (The manner and skills of the nurses undoubtedly helped with this, though it appears that persuasion of any form was unnecessary.)

“Do you have any other questions for me before I go?” I asked. Last time, I simply told him that I was leaving. First, do no harm.

“No,” he said, smiling. “Thank you for talking with me. I hope you have a nice day.” He waved.

“Thank you,” I said, waving back.

Wondrous!

Categories
Medicine Nonfiction Reflection

Assuming Intentions from Behaviors.

The fear first appeared in his eyes, then washed over his entire face.

“Hey, how did you do that?” His voice grew louder. “You’re supposed to help me! How did you tell the voices what to say?”

I realized that this was not going to end well.

“The voices in my head are now saying that there are robots in my brain!” he shouted. “That’s illegal! You’re not allowed to do that!”

“I have no ability to put voices in your head or anyone else’s head.”

“But you did! Before you told me about what I supposedly said the other day”—he had told my colleague that there were robots in his brain—“the voices never talked about robots. YOU did this!”

“I did not.”

“You did!” He looked around, frantic. “HELP! SOMEONE HELP ME! THIS NURSE IS PUTTING VOICES INTO MY HEAD!”

My heart sank further. Many people who experience auditory hallucinations learn to avoid sharing this with others. This man did not realize how others would dismiss his suffering.

“I’m going to go.”

“NO! You can’t go! You’re doing something illegal!” He saw an officer approach. “GUARD! GUARD! This nurse is doing something illegal! She’s putting voices in my head!”

Though he has worked on the unit for years, I suspect that he had some innate skills in talking with people who were overwhelmed.

“Hey, you don’t need to yell, I’m right here. She’s trying to help you….”

He managed to shout, “HEY, COME BACK HERE, YOU NEED TO STAY!” as I slipped away, but he stopped yelling before I was out of earshot. The officer later told me the man demanded that I call his parents to tell them that I was putting voices in his head.

There’s no way this could ever happen to you, right?

But aren’t there times when we believe that someone did something to us… except they didn’t?

Like those times when we say, “She makes me so mad!”

Or, “He’s trying to make me jealous.”

We assume intention from behaviors. Sometimes our assumptions are correct, but not always. We feel whatever emotions we feel, but that does not always mean that somebody else is responsible for our emotions.

“But, Maria,” you might retort, “there’s a big difference between hearing voices and feeling emotions. We all feel emotions. Only sick people hear voices.”

… except there’s data[1. Prevalence of auditory verbal hallucinations in a general population: A group comparison study and A comprehensive review of auditory verbal hallucinations: lifetime prevalence, correlates and mechanisms in healthy and clinical individuals.] that suggests that anywhere between 5% and 28% of the general population hears voices. They are your coworkers, friends, members of your family, people you routinely see in your community.

And even if we don’t hear voices, our running internal dialogue—while not “voices”, per se, but “thoughts”—can transform an event into something else that never actually happened.

I felt sad as I was walking away from this man. First, do no harm. Our conversation went sideways and caused him distress. I replayed the interaction in my mind—my own internal dialogue was loud—and recognized several points where I could have taken a different approach. The outcome still may have been the same.

The truth remains, though: I did not put voices into his head. I don’t know how to do that. My hope is that he will recognize and accept that in time.

Categories
Nonfiction Reflection Seattle

What Makes America Great.

After a long gaze at the different fonts and bright colors, my father, a Chinese man in his 70s, concluded in English, “The menu is different.”

“Yes, it’s new. Today is the first day,” replied the clerk, a Latina woman in her 40s. Standing next to her was a young Latina woman, perhaps not yet 20 years old.

“It used to be K5,” my father murmured in Chinese.

“Do you want what you usually get?” I responded in Chinese.

Though my father has an excellent grasp of English, the new orientation and colors of the fluorescent menu perplexed him.

“Yes….”

“Chicken legs, right? You want K1.”

My dad found K1, too, and nodded with approval. He directed his attention to the cashier.

“Can I please have K1?” he asked.

The older woman nudged the younger woman to show her how to enter this order. “Ask if he wants original or extra crispy,” she advised in English.

“Original or extra crispy?” the young lady parroted.

“Original,” my dad said. The older woman then began to give instructions to the young woman in Spanish.

“It’s her first day here,” the older woman offered. The young woman smiled sheepishly; we all smiled back at her. No big deal.

And so it went: Spanish behind the counter, Chinese in front of the counter, with English connecting the two sides, and people helping people in all directions.

This is what makes America great.