Category: Nonfiction

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Funding Homelessness Nonfiction NYC Policy Reflection Seattle Systems

God’s Work versus Meaningful Work versus Value.

Every now and then, when some people learn what kind of work I do, they say, “You’re doing God’s work. Thank you.”

They mean well, so I accept the compliment, though I also tack on, “I also like what I do. It’s meaningful work for me.”

So many of the people I see, whether in my current job or in my past jobs working in other underserved communities, have a lot going on that psychiatry and medicine cannot formally address. One example is housing. It is often an effective intervention for the distress of people who don’t have a place to live, though housing is not something physicians can prescribe. However, there are individuals who are eligible for housing, but do not want to move into housing for reasons that do not make sense to most people. For example, in New York I worked with a man who would spend his days sitting in front of the building where he once worked before he became ill. He talked to himself and burned through multiple packs of cigarettes. He did not recognize how soiled his clothes and skin became with time. At night he disappeared into the subway tunnels and rode the trains. He did not want to move into an apartment until he was able to get his job back, even though he hadn’t worked there in over ten years. With time (nearly two years!) and unrelenting attention, our team was able to persuade him to try living indoors. He eventually accepted the key and moved in.

There are other active conditions that I do not have the skills to treat: Sometimes it’s institutional racism; sometimes it’s multiple generations of poverty. Both prevent people from accessing education, housing, and other resources. Do some of these individuals end up taking psychotropic medications due to the consequences of these systemic conditions? Yes. Do I think they’re always indicated? No.

Most of my jobs have been unconventional: I worked on an Assertive Community Treatment team that often provided intensive psychiatric services in people’s homes. I worked with a homeless outreach team and did most of my clinical work in alleys, under bridges, and in public parks. I worked in a geriatric adult home and saw people either in my office, which was literally the storage room for the recreational therapist’s stuff, or in their apartments if they were uncomfortable seeing me in the storage room. I was recruited to create and lead the programming for a new crisis center whose goal was to divert people from jails and emergency departments.

And now I work in a jail.

As time progresses, it has become clear to me that I have not had the typical career for a psychiatrist. I like that. However, I often also feel out of touch with my colleagues. I believe that they are all trying their best, but they don’t have the time to see how systems end up failing the most vulnerable and ill in our communities. They work in the ivory towers of academia and don’t seem to realize the dearth of resources—financial, administrative, academic—in the community. They work in private practice and don’t seem to realize how ill some people are and how we need their expertise. They work in psychiatric hospitals and seem to believe that some of these individuals will never get better when, in fact, they do.

Because much of my work has been outside of the traditional system, I consider myself fortunate that I have been able to escape the box of simply prescribing medications. Many of the individuals under my care do not want to take medications. Their desire to not take medications, though, doesn’t stop us from working with them. We meet them where they are at and remember that they are, first, people. As we are in the profession of helping people shift their thoughts, emotions, and behaviors, we believe that there will come a time—maybe soon, but maybe not for weeks, months, or years—that something will change. Just getting someone to talk to us becomes the essential task. This is true whether someone is in a jail cell, living in a cardboard box under a bridge, or residing in a studio apartment.

Should systems pay psychiatrists to do this work? Maybe it’s not “cost effective” because of its “low return on investment”. After all, this task of “building rapport” means psychiatrists aren’t working “at the top of their licenses”. If a psychiatrist is able to get people to talk to her and help them shift their behaviors, whether or not that involves medications, does that have value?

Does the psychiatrist’s efforts have value if it helps the “system” save money?

Is there value if it reduces the suffering of these individuals who have had to deal with police officers, jails, and living on the streets due to a psychiatric condition?

Perhaps my idealism blinds me. One of my early mentors in New York City often said, “I want the guy who lives under the Manhattan Bridge to have a psychiatrist who is as good as, if not better than, the psychiatrist who has a private practice on Fifth Avenue.” I couldn’t agree more.

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Education Nonfiction Reflection

Primary and Secondary Emotions.

I used my left arm to stop the tears from rolling off my cheeks and onto the lotus root. Had I known that Act One of episode 597 of This American Life would make me cry to the point that I would have to wipe the snot from my nose multiple times with my arm, I wouldn’t have listened to it while making a lotus root salad for a party.

People warned me that my grief about my mother’s death would continue to fluctuate with time. It had been many months since I last cried; how was I to know that learning about the wind telephone in Japan would induce such a reaction?

Perhaps my grief wasn’t my own. My father’s older brother recently died.

“I’m glad I could help with the funeral arrangements for him,” my father murmured to me. “I went through all that just three years ago, so I knew what to do.”

I nodded. He sighed.

“He was my older brother. It was still a shock.”

I looked away. He didn’t need to see his daughter trying to hide the sadness from her face.

I first learned about “primary” and “secondary” emotions while learning dialectical behavior therapy. Marsha Linehan points out that there is

a distinction between primary or “authentic” emotions and secondary or “learned” emotions. The latter are reactions to primary cognitive appraisals and emotional responses; they are the end products of chains of feelings and thoughts. Dysfunctional and maladaptive emotions, according to Greenberg and Safran, are usually secondary emotions that block the experience and expression of primary emotions.

Some (corny) examples are helpful here:

Primary emotion: “All right! I did well on that test! I feel happy about my performance!”
Secondary emotion: “But wait! I still missed some items on the test. I feel ashamed that I felt so happy about how I did. It’s not like I got a perfect score.”

Primary emotion: “I can’t believe she did that! Who does things like that, anyway? I feel angry.”
Secondary emotion: “Maybe I’m overreacting about her. I don’t want people to think I’m a b!tch. I’m disappointed that I can’t control my moods better.”

Not much time has to pass between the primary and secondary emotions. In fact, sometimes people experience only the secondary emotion. The experience of the primary emotion gets lost, even though the primary emotion reveals useful information about the situation and how the person relates to it.

Infants and children experience and express primary emotions. We become acquainted with secondary emotions as we age.

Primary emotion: I feel sad about the death of my mother. I witnessed how her death affected my father, who lost his companion of forty years. There are things that only my father and I understand; we can’t talk about those things with anyone else because they just won’t get it. I feel sad that he is at that age where multiple loved ones are dying because their time has run out. I feel sad when I consider the loneliness he must feel at least some of the time.

Secondary emotion: God willing my father dies before I do: No father should outlive both his spouse and child. Of course I will feel grief when he dies. Will it be worse than the grief I felt when my mother died? What if it’s too much grief? What if I don’t have the mettle to tolerate it?

What will I do when my only option is to use a wind telephone?

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Nonfiction Observations Reflection

A Thousand Years.

I recently had the opportunity to visit two places in New Mexico: Chaco Culture National Historical Park and the Very Large Array.

The Chaco Culture National Historical Park features now ruined pueblos that people built over a thousand years ago. Construction started on Pueblo Bonito, a structure that archaeologists believe contained over 600 rooms, around 850 AD! Additions and revisions occurred on Pueblo Bonito for the next two hundred years. There are ruins of other pueblos in the area; some of them are now crumbling walls that have succumbed to the eroding powers of the desert winds and blazing sun.

Petroglyphs and the orientation of these ruined pueblos suggest that the people who lived in or visited Chaco appreciated their relationship with the celestial universe. A sun dial, located on a butte that is no longer open to the public, reflects their observations of the equinoxes and solstices. People, then and now, witnessed the directional relationships the buildings have with the stars.

The Very Large Array, on the other hand, was constructed over forty years ago. The 27 enormous dish antennae, arranged in a Y configuration, sense radio waves coming in from the universe. These antennae function as a giant “eye” and funnel the signals they receive to a supercomputer. Scientists analyze data from this supercomputer to describe events that have occurred in the universe: Stars exploding, the birth of new stars, and the location of black holes.

The antennae are arranged in straight lines, which are in stark contrast to the curves and shapes of the surrounding mountains and clouds. Such straight lines do not occur in nature—even trees are not so rigid.

What if Chaco and the Very Large Array serve the same purpose?

What if Chaco was an effort to better understand the universe and what was in it? The Very Large Array gathers data from invisible radio waves; Chaco collected data from visible waves from the sun, moon, and stars.

If people excavate the Very Large Array a thousand years from now, what will they think? Will they look upon the Very Large Array with the same wonder that we feel when we look upon Chaco?

I have noted before that death is the great equalizer. It puts everything in perspective.

In a thousand years, who will know your name? That thing you’re worried about now: Will it matter in a thousand years? Your creations—children, music, writings, meals, home improvements, tweets, laws, relationships—what impact will they have in a thousand years?

To be clear, I am not saying that what we do now has no importance or value.

There are things we do now that have huge significance and meaning. Sure, that kind act you do today won’t enter the annals of history. However, that same kind act will make the world an easier place for someone who is suffering now. Maybe the melody of that song you wrote will fall silent once you die, though it brings joy now to someone who delights in music. What you do now may not last forever, but that shouldn’t stop you from doing those things. What you do matters.

And maybe the remnants of something you create will still be around a thousand years from now. If that is the case, consider how your creations can inspire and humble the people of the future. The mysteries that you want to understand now may still be mysteries hundreds of years from now.

Someone said this a thousand years ago, and someone else will say this a thousand years from now. This is a reminder for us all today.

Categories
Education Medicine Nonfiction Reflection

A Week in School!

I spent the past week at a health care ethics seminar. Here are some reflections:

How lucky was I to spend a week in school? The last time I sat in a classroom for five consecutive days was about 15 years ago. Prior to starting my clinical rotations in medical school, I was a professional student: There were 18 years between kindergarten and my second year of medical school. I got really skilled at sitting in classrooms, listening to people talk at me, and organizing the information for either tests or real-world application.

I’ve recognized the privilege of attending school. I don’t think I appreciated the depth of this privilege until this past week.

Different perspectives makes for rich learning. Most of the students in this seminar came from three professions: Chaplains, nurses, and physicians. There were some social workers, as well as an attorney or two.

There were further divisions within those groups: Some people were professionals within the military; others came from Catholic hospitals; multiple medical specialties were present. Most of the people there were already participating in ethics committees.

The different perspectives that each profession, specialty, and individual brought were useful. Decisions by committee can be onerous (cf. the pain of some meetings), but discussing and learning within committees is often humbling and fascinating. My classmates brought up ideas and arguments that I would not have considered.

One wonders if these rich discussions occur because we know our time together as a group is limited. In standing meetings in our usual jobs, we sometimes get accustomed to who says what and why. We might also face formal or informal consequences for speaking up (or not speaking up). In a week-long seminar, what have you got to lose by sharing your thoughts?

On not speaking up. As both a student and physician, I continue to receive feedback that I should talk more. (Given how much I blather here, one might find this surprising.) When I was a student, sometimes teachers thought I didn’t care about the topic. (Usually untrue.) Sometimes they thought I was shy. (I’m not, though people who haven’t gotten to know me might think otherwise.)

These days, sometimes people wish I would speak up to demonstrate my expertise. Sometimes I get the impression that some people want to know what I’m thinking, but when I don’t speak, they believe I’m withholding information on purpose. (Rarely true.)

There was plenty of dialogue that occurred between teacher and student and between students during the lectures. I said little. The admonitions from my past (and present) echoed in my ears: “You’re not talking! You’re not contributing to the group! Why don’t you say something and help out?”

Honestly, I think I’m just a slow thinker. It’s not that I don’t have opinions; I just find myself thinking about multiple perspectives at the same time. This muddles my thoughts. Muddled thoughts often leads me to produce incoherent speech. While I’m slowly clarifying a single line of thought, others who are able to organize their thoughts faster have raised their hands and are ready to speak.

Health care ethics isn’t limited to death and dying. Most of the discussions we had during the seminar surrounded death and dying. For example: A child is in a coma in the intensive care unit. The medical team wants to proceed with further interventions and treatment that has a 50% chance of recovery. The parents of the child want to withdraw treatment, which means imminent death. Discuss.

I imagine that most ethics consultations in the hospital are related to death and dying. But what about all the other ethical quandaries that are not as “glamorous”, but occur more frequently?

Like informed consent for medications. How much informing is “enough”? How much detail of the risks, benefits, and alternatives should we offer? If someone doesn’t want the information, but wants the treatment, is that a valid consent?

When I was a resident, one of my attendings commented in half-jest, “A common problem with informed consent is that by the time someone is truly informed, they are not able to provide consent… and when someone consents, they are not truly informed. Consider someone who is experiencing CPR: The chest compressions, the mouth-to-mouth breathing, the ribs breaking. That person is completely informed about CPR now… but he can’t consent. But when we obtain consent about CPR, that person usually has no idea what happens during CPR.”

Involuntary treatment is a big deal in psychiatry (as it should be). Sometimes we don’t seem to devote sufficient attention to all of its ethical issues.

The value of teachers showing vulnerability. Some of the speakers at this seminar take care of patients. They offered real clinical examples of ethical quandaries (e.g., a patient who doesn’t want to know her diagnosis, even though the physician believes that the patient should know). Those discussions were the most compelling because these teachers had opinions about what to do, but were not sure and still are not sure if they did the “right” thing.

I admired the thoughtfulness and humility of these speakers. Ambiguity is present in all of medicine. Sometimes we—all of us, regardless of our role—want a clear, concrete answer, but it doesn’t exist. Sometimes people craft an answer to reduce the motion sickness they feel while floating on the sea of ambiguity. It takes courage to recognize that sometimes there is no anchor, that the clouds are blocking the stars, that we don’t know where we are or what to do next. We just do the best we can with the information we have at the moment.

The value of pithiness. Several of the instructors seemed to speak solely in aphorisms. It didn’t matter how muddled or disorganized our questions were; they reformulated our questions with wisdom and clarity and provided concise answers.

I wish I could do that all the time.

Each instructor highlighted the importance of clarifying the ethics consultation question. This idea was also drilled into our minds as psychiatry residents when we were learning how to do hospital consults. What is the question? It doesn’t matter how great the answer is if it doesn’t actually address the question. And sometimes we don’t know what we’re asking.

Pithiness comes from clear thinking. Clear thinking comes from understanding the issue at hand. We don’t understand the “issue at hand” unless we ask questions.

Of course, these instructors have been thinking about ethics for years. They have likely heard our questions or some variant of them before. The various moral frameworks (e.g., utilitarianism, deontology, virtue ethics, etc.) are novel to us, but not to them.

It also takes time to think clearly. The time pressures inherent in clinical medicine contribute to muddled thinking or, in the worst case scenario, not thinking at all. This is yet another reason why I was grateful to attend this seminar: There was time to think, reflect, and consider the “bigger” picture of the work we do.

As I’ve noted before, the more experience I get, the more I realize how much I don’t know. (It’s disturbing.) This is why I now value more how to think, rather than what to think. The content changes over time as psychiatry makes (slow) advances. Knowing how to apply this information in the service of caring for patients is paramount.

For those of you interested in health care ethics, the primary paradigm this seminar used is called the “four boxes“. Look over my Twitter timeline for more comments about the seminar (though I stopped sharing much after day three, only because my mind felt full).

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Education Lessons Medicine Nonfiction Reflection Seattle

It’s Good to be Busy.

It was a busy day:

There was the guy who spoke with enthusiasm about his doctrine of RUL (“Righteous Unconditional Love”); the man who stared through me after I asked him about whether he had eaten that morning; the fellow who made no efforts to hide his nose-picking while expressing his frustration with the court system; the young man who wouldn’t let me inspect the wound on his hand, though I soon recognized that he had crafted the wound out of a packet of juice crystals; the man who hadn’t taken a shower in several months, though the odor bothered me more than it bothered him; the guy who boasted about his abilities to run a mile in two minutes; the man who refused to acknowledge my existence; the fellow who advised me that he would prefer to take his medications in the morning because that’s what his nurse practitioner told him to do; the man who apologized for masturbating, but argued that he is young and “that’s what young people do”; the fellow who said that after he used “bad heroin”, he realized that his parents aren’t actually his parents; the guy who found lithium energizing and was in the process of tapering off of methadone; and the man who simply said, “I’m not sick,” when I asked him why he hadn’t been taking medication that the state psychiatric hospital had prescribed to him. Nurses paged to ask for orders for medications to reduce the discomfort of heroin withdrawal, medications that patients had asked for three days ago, medications that patients took before they entered jail. The phone rang as callers shared information about diagnosis, treatment, and next steps.

I tipped my head back in the chair, stretched my arms up, and sighed.

“You okay?”

It was my second year of residency and I was the only psychiatrist in the hospital that night. My duties included addressing any issues that occurred in the psychiatric unit and providing care for any patients that came to the emergency department with psychiatric concerns.

My classmates had warned me about a particular emergency medicine attending physician who was working that night:

  • “Last week he told me I was useless.”
  • “He rolls his eyes at me all the time.”
  • “He’s just angry. He won’t ever thank you for anything you do.”

“Hi, Dr. Angry,” I said around 7pm. “I’m the psychiatry resident on call tonight.”

After glancing at me, Dr. Angry grunted.

Well, I guess that’s how it’s going to go tonight.

Less than three hours later, after Dr. Angry referred four patients to me, he muttered in my direction, “I’ve got another one for you.”

Shortly after midnight, a patient’s husband was pulling her out of the ED while she was screaming at me.

“I’M GOING TO GET YOU FIRED FROM HERE! YOU’RE A TERRIBLE DOCTOR! I KNOW THE PRESIDENT OF THE HOSPITAL! YOU CAN’T DO THIS TO ME!”

I was shaking, but I wasn’t going to admit her to the hospital. Dr. Angry caught my eye and nodded once. I wasn’t the only person who knew I was shaking.

It was close to 3am and I had already seen seven patients.

Dr. Angry had a slight smile on his face as he approached me while I was slogging through my notes.

“Dr. Yang, there’s another one for you to see.”

please make it stop

“Thank you. Who is it?”

As I was beginning my note around 6am for the ninth patient I saw, Dr. Angry stopped by.

“Dr. Yang, you did all right. Thank you.”

“You’re welcome, Dr. Angry.”

I tipped my head back forward in the chair in the jail and dropped my arms.

“Yeah, I’m fine,” I replied to my colleague. “It’s busy, but it’s good to be busy. And when I think about my intern year, this isn’t bad at all.”