Category: Nonfiction

Categories
Informal-curriculum Nonfiction Reflection

Bias.

“I’ve been alive for too long,” he sighed. “I will be 200 years old in two months and four days. I was born in 1817, you know.”

“200 years is a long time,” I replied. While he wasn’t 199 years old, the wrinkles around his eyes, the knobbiness of the knuckles on his hand, and his slumped posture made him look older than his actual age.

“I’m an angel,” he continued. “I do what I can to help people, as that is my mission from God.” His thin frame quivered as he coughed into the crook of his elbow. “God sent me down from heaven 200 years ago. People are drawn to me. Animals are drawn to me. They know that I can help them. I give away my food, I give away my cigarettes, I give away my marijuana. God gives me instructions about how to best help people.”

“Would you miss God’s voice if it went away?”

The Angel bit his thin lip before responding. “Maybe.” He looked worried.

“You seem to appreciate the guidance,” I said, though we both recognized that I was actually asking a question.

“Sometimes God says helpful things,” the Angel answered. “Sometimes… not.”

He shared that sometimes demons speak to him, too. They whisper and shout amidst his thoughts, pointing out how his efforts are useless, that no one cares, that there is no value to his life.

“What has stopped you from killing yourself?”

The question had barely left my lips before he answered, “It’s a sin.”

The cases of beer helped to mute the voices of God and the demons, which often became a cacophony when the light of heaven was gone. No, he didn’t think that the beer was hurting his liver; maybe it was even helping it.

“I didn’t get the hepatitis from drugs,” the Angel offered. “I wasn’t feeling good, I was sick. The doctor tested me and said I had hepatitis. He told me that I had to tell anyone I was having relations with. When I told the lady I was seeing at the time, she said, ‘You got that from me.’ I wish she had told me that sooner. I would’ve used protection if I had known that.”

The Angel didn’t know when he was getting out of jail. We discussed what treatment would best help him. When I asked if he had any questions for me, he shook his head.

“Feel free to come back any time to talk,” he said with the same polite manner he showed for the half hour we spoke. He bowed his head.

You can look up an inmate’s charges on the internet. It’s public information. You won’t learn what specifically happened that resulted in the arrest, but you will learn the alleged reason for why the person is in jail: Robbery. Assault. Failure to appear for court. Theft. Domestic violence.

I don’t seek that information before I meet my patients in jail. If patients start sharing their understanding as to why they’re incarcerated, I stop them. My duty is to the patient, not to the court or the attorneys.

When I first started working in the jail, I looked up the charges for all of my patients, as that information has the potential to help with clinical care. What I saw quickly dissuaded me from doing this on a routine basis.

It is uncommon for a man of the Angel’s age to be in jail. Yes, he was reporting and demonstrating psychiatric symptoms, but they alone did not explain why he captured the attention of law enforcement. Why would a man with his gentle manner and feeble condition be in jail?

Failure to report: sex offender.

The Angel had two convictions: One for Rape, the other for Indecent Liberties With Forcible Compulsion. These occurred years apart.

“Sometimes God says helpful things,” the Angel answered. “Sometimes… not.”

Categories
Informal-curriculum Lessons Medicine Nonfiction Reflection Seattle

Crossing Streets.

I didn’t mind that I had to wait to cross the street. The yellow-white light of the Spring sun shimmered in the infinite depths of the lapis lazuli sky. The afternoon breeze lifted the fragrance of sweet flowers over the concrete and fluttered the short sleeves of my summer blouse.

Then I heard a man. He seemed to aim his voice, full of gravel, towards me.

“WOOOO WHEEEE!” He chuckled. “Lawd have mercy!”

ignore him don’t turn your head ignore him don’t look ignore him stay still

My peripheral vision saw his tall figure approach me before I heard him: “Doctah!”

okay he is probably talking to you take a breath

I turned. Though his pants, tee shirt, and jacket were all too large for his frame, it was a stylish look on him. His baseball cap was on backwards and pinned his dreadlocks away from his face.

“How you doin’?” he greeted, his smile revealing several missing teeth. He extended his right fist, a wordless invitation to extend my fist for a bump.

“So what are you supposed to do when you see your patient out in public?” We all looked at the professor with great expectation.

“What do you think?” (Of course a professor of psychiatry would answer a question with a question.)

“Well, you want to respect the patient’s privacy, so you probably shouldn’t say anything.”

“But what if your patient sees you first? And says hi?”

“It seems rude if you don’t say hi back. But if your patient is with another person, that could get awkward fast. What if the other person says, ‘How do you two know each other?'”

“I’d probably go out of my way to avoid my patient. I’d cross the street or something.”

“But that’s weird, too. Your patient might wonder why you’re avoiding them.”

“Or my patient might appreciate that I am keeping the boundaries clear.”

“If my patient said hi to me first, then I would probably say hi back and then try to get away as soon as possible.”

“What do you think they do in smaller communities? Doctors and patient see each other all the time when they shop for groceries and stuff.”

“That might be embarrassing: I don’t want my patients seeing me in sweats when I’m shopping for food.”

“Why are we assuming that patients would want to talk with us in public, anyway?”

The group reached a consensus: If you see your patient, but your patient doesn’t acknowledge you, don’t acknowledge them. You have a duty to keep things confidential. If your patient says hello to you first, be a person and say hello back, but keep it superficial and brief. And the next time you see each other, ask the patient how s/he would like to proceed in the future if you two run into each other again.

“I hope I never run into my patients,” someone mumbled.

The most memorable patient run-in I’ve had in a public setting occurred on a bus.

I was sitting in the back half of a double-length bus. Most of the seats were occupied and a few people were standing in the aisle. The grassy trashy odor of marijuana wafted from the rear of the bus. A young woman, who was under my care several times at a crisis center, and a young man boarded the bus. She saw me first.

“Hey! Doctor! How you doing?” she shouted at me. I nodded back at her. The older woman sitting next to me shot a glance at me, then sighed.

The young woman grabbed the young man’s hand and pulled him down the aisle. The two or three people ahead of them had no place to sit, so they halted and turned around. The young woman was thus about six feet away from me; she couldn’t get any closer.

As the bus lurched into motion, she leaned around the two or three people and raised her voice over the rumble of the engine: “Hey, Doc! I’m doing better these days! I haven’t been to the crisis center in like a month!”

“That’s good,” I replied. Maybe this will be the end of the conversation.

“I still take the Seroquel and Depakote now,” she continued. “Those meds really help. I take them every day.”

There was no street for me to cross. Okay, I guess this is really happening.

“But the meds are expensive! I want to keep taking them, but they cost a lot. Do you know where I can get meds for cheap?” Her eyes were eager.

The older woman sitting next to me heaved another sigh and closed her eyes.

Okay, if we’re going to do this, let’s really do this, then. I took a deep breath.

“Target has a four dollar list and those medications might be on that list. So, best case scenario, each medication will only cost $4 a month. Costco also has medications for cheap, sometimes medications that aren’t on the Target list. You don’t need a membership to use the pharmacy there.”

“For real? I can get medications at Costco without being a member?”

“Yeah. It’s a good deal.” Maybe someone else on the bus can use this information, too.

“Okay, cool. Target and Costco. Thanks, Doc!” She turned to the young man and began planning where they would get food for dinner.

As I stepped off the bus a few stops later, she called, “Bye, Doc! Thanks again!” I smiled and waved.

“Hi!” I said to the man with the gravel in his voice. you look familiar but how do I know you jail yes you were my patient in jail and what is your name what is your name wow you look so different but of course you do because you’re wearing regular clothes and you’re smiling and you’re outside on this beautiful day

I extended my right hand. We bumped fists.

“I’m doin’ real good, Doc. I take my meds every day and I live here.” He pointed to the handsome brick building down the street. “I ain’t picked up in a while and I’m takin’ care of myself. Things are good, Doc.”

“I’m glad to hear that.” I smiled.

“How you doin’?” he asked again, the gravel rattling in this throat.

“I’m well, thank you.”

“Well, you have a blessed day and you take care of yo’self!” He laughed and pointed at me while he walked away.

The white walking man appeared on the traffic light. I crossed the street. I was still smiling.

Categories
Nonfiction

Tourist.

“I wanted to see Boeing and Microsoft,” he said. He wiggled his bruised fingers that poked out from the white cast on his arm. The red uniform was too big for him.

“And now he’s in jail,” the interpreter murmured.

Three weeks prior, he bought a plane ticket online. He wanted to visit Seattle.

When he boarded the plane three days ago, he felt uneasy. Something wasn’t right. Something was going to happen.

He prepared himself for the long flight. Seated next to him was someone who looked like him, one of his people. They greeted each other in their native language. The dull roar of the plane engines lulled him to sleep…

… and when he woke hours later, he muffled his gasp. The person sitting next to him now had different hair and eye colors, and only spoke English. And yet it was the same person he had greeted only hours before. How could this be?

It would only get worse. He said nothing on the tour bus and retired to his hotel room, though was called back out again for dinner.

Something still wasn’t right. He ate quickly.

After dinner he sat in the lobby of the hotel. He chewed on his finger.

Someone else is in my hotel room. It’s not safe.

A man wearing dark clothing walked through the lobby and looked at him. A few minutes later the same man walked through the lobby and looked at him again. And then it happened a third time.

Fed up with this surveillance, he tried to ask the hotel staff to call the police. They didn’t understand or speak his language, so they didn’t understand why he wouldn’t return to his room. He couldn’t understand or speak English well, so he didn’t understand that they were calling the police because they were worried about him. There was no man in dark clothing.

When the police arrived, they asked him to go to his room. He refused.

He then grabbed one of the police officers and bit him.

There was a scuffle and he started yelling. One of the bones in his arm broke. The police took him to the hospital.

The physicians at the hospital all agreed that he was quiet and polite. He said nothing to them about the uneasiness he still felt, the transformation of the person on the airplane, the man in dark clothing who was watching him, or the person who invaded his hotel room.

“If we don’t operate on your arm now, the bone won’t heal right. Your arm will be crooked for the rest of your life.”

“I understand, but I don’t want to pay for the surgery. I don’t have enough money. I can get the surgery done when I go home.”

“You can pay for the surgery once you get home. You really need to get it done now. Your arm might even hurt for the rest of your life if we don’t fix the bone now.”

“I understand that. It might be crooked, it might hurt, but I don’t want to pay for it here. I will get it fixed at home.”

He didn’t tell the phone interpreter that God would heal his arm in the next few days. Why ask man to fix his arm when God would heal it with perfection?

His bail was set at $50,000.

“Where is he going to get $50,000? Does the consulate know about him? Does he know anybody in America? Does his attorney speak his language?”

He stood up whenever the jail officers approached his cell. He learned to say “thank you” and repeated those two words whenever the jail nurses tended to his arm and gave him medicine. He folded his blanket and the leftover wrappers of his meals into neat squares.

“Everyone has been nice to me here,” he said. A smile bloomed across his face.

He finally agreed to take a shower. It had been nearly a week. After he rubbed the thin towel across his skin and put a clean uniform on, he left the dripping cast outside of his cell.

Psalm 34:20: He protects all of his bones, not one of them will be broken.

While he was at the hospital to have the cast reapplied to his arm, someone posted his bail. The jail officers who had accompanied him there came back alone.

Where did he go?

Who paid his bail? Did someone pick him up from the hospital? Did he return to the jail to pick up his wallet and clothes? How did he get to the airport? Did he go to the airport? Did someone already purchase a plane ticket for him?

How did he tolerate the plane ride home? Did he go home?

Did the government of his home country post his bail? Did it also buy his plane ticket? Did he undergo surgery for his arm at home? Did they know that he believed that God would heal his arm? That someone was following him?

What did he tell his friends and family? He wanted to see Boeing and Microsoft. He was a tourist and ended up in jail.

Would they believe that?

Categories
Nonfiction Observations Reflection

Reflections from the National Council Conference.

So I attended the National Council for Behavioral Health conference[1. The National Council also named me a “top tweeter“. Two people suggested that I add that to my CV.] last week with close to 7000 other people, the vast majority of whom were not my closest friends. When I reflect back over the conference, three and a half talks come to mind as noteworthy:

Mess Up Your Costing and It Will Cost You Everything. I was not the target audience for this talk. Scott Lloyd, the president of a consulting company associated with the National Council, noted that the intended audience included CEOs and CFOs. And, indeed, much of his talk focused on managing costs in a behavioral health organization so expenses don’t exceed revenue. Like many other talks at the conference, he highlighted the use of data, making it transparent to all staff, and encouraging financial leadership at organizations to explain what the data means so staff understand what they’re looking at.

What struck me most about his talk, though, was the amount of time he spent telling the audience—repeatedly—that they cannot demand their clinical staff to “do more”. He recognizes that clinical staff are already doing as much as they can. He instead urged the audience to do whatever they could to make the lives of their clinical staff easier (e.g., reduce documentation burdens). That helps organizations retain staff and promotes staff satisfaction.

It’s always nice when an administrative leader advocates for the workforce. And I got to learn more about the lens CFOs and CEOs use while at work.

Fireside Chat with the Surgeon General. I’ve already written about my impressions of the Surgeon General when he spoke to a room of about 30 people. This time, Admiral Murthy was on a stage in front of several thousand people. He told stories; he spoke about the important people in his life who have shaped his worldview; he spoke with humility about his role.

He didn’t share groundbreaking policies or ideas. He simply shared himself and his values with the audience. His wisdom and grace seems uncommon in people of his age and status.

Listening to him speak made me reflect upon what I do in my professional roles. His talk inspired me to do and be better.

Fireside Chat with CMS. I don’t understand all the regulations that come out of the Centers for Medicare and Medicaid Services (CMS), which is why I decided to hear what CMS had to say.

I was surprised when the CMS representative identified himself as the chief medical officer! Of course CMS would have a medical director, though I didn’t expect that he would speak at this non-physician conference. I was delighted to learn that Dr. Patrick Conway continues to see patients as a pediatrician. He asked for ideas and feedback from the audience and didn’t run away when his scheduled time was over. (A mob of close to 30 people, out of an audience of several hundred, came up to him afterwards to ask him more questions.) He acknowledged that the regulations that CMS imposes get in the way of innovation.

Sometimes I forget that some people who work in bureaucratic administrations want things to change, too. It’s also hard for a single person to change the direction of a bureaucracy. However, I appreciate the efforts of these single individuals because at least they’re trying. I also appreciate Dr. Conway making himself open and available to field questions from a room of people who may not have the warmest feelings towards CMS.

Social Determinants of Health. Two speakers shared the hour to discuss their respective activities. One speaker was Dr. Michael Sernyak, who spoke about his efforts in addressing “food insecurity” and nutrition in a community mental health center he oversees in New Haven, Connecticut. He shared his story about working with community partners to improve the quality and nutrition of food served in the center, which included cultivating a community garden, hiring a nutritionist, and providing explicit training to both staff and patients about the role and importance of nutrition in (behavioral) health care. He also spoke about the unintended benefits of this program: Apparently residents who live near the community garden have reported that the neighborhood is now safer.

The National Council is not a physician conference. He noted that, when his gave this exact same talk at the American Psychiatric Association conference, which is a physician conference that also has an attendance of thousands of people, only four people attended. At this conference, the room was packed: People standing at the perimeter of the room and others sitting on the floor in the aisle.

I liked both the simplicity and elegance of his vision, particularly since food affects health in more ways than one. I also appreciate that, while this intervention was simple, it was not easy.

I’m grateful that I was able to attend the conference and learn what other people are thinking and doing. I won’t lie: I also followed all the suggestions for coping with the conference and still felt cognitively impaired by the second day. Quiet and solitude are wonderful things.

Categories
Medicine Nonfiction Observations Policy Systems

Disappointment.

My cohort graduated from our psychiatry residency almost ten years ago. The level of frustration and disappointment we’ve all experienced within the past two years is striking.

Some have taken leadership roles, only to relinquish them because of fatigue from fruitless discussions with administrators. Others have tried to alert senior managers about dangerous and irresponsible clinical practices. Their efforts were unsuccessful because concerns about finances trumped concerns about clinical services. With a bad taste in their mouths they resigned from their positions. Still others have tried to convince senior administrators about why certain clinical services are necessary. Though these clinical services save money across systems, they do not generate revenue for any specific organization.

“Just keep quiet and keep doing what you’re doing,” they hear from a few senior managers who are sympathetic to their efforts. “Maybe you can stay under the radar that way.”

One had the job duties of three positions. This physician asked for help after recognizing that this workload wasn’t sustainable. The administrators repeatedly said no. And, yet, when this physician finally resigned, the administrators split the single position into three.

“It’s like no one cares about about human suffering. It’s always about money.”

Some have become medical directors, only to learn that senior leadership expect a rubber stamp of agreement from them as figureheads to help change the behaviors of medical staff. Many of their clinical recommendations go unheeded because mandates from policy advisors and economists have primacy. For-profit corporations value profit over patients and seek the counsel only of their shareholders.

They have noticed that administrators often value the “medical doctor” credential for their reports over the clinical expertise of the person with the credential. They recognize that they are often not invited to certain meetings because some administrators do not want to hear what they have to say. They thought that they could offer specialized knowledge to proactively improve systems, but they learned that systems only react to audits.

We all sit around the table, the occasional fork clinking against plates holding desserts. No one talks because no one knows what to say. If we’re all experiencing this across different clinical settings and organizations, what encouragement could we offer?

What do we say to our patients?