Category: Nonfiction

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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?

Categories
Nonfiction Observations Reflection

(Stupid) Status Games.

I only noticed later that he had a taser on his belt, which means that he was probably a sergeant.

After the doors closed and the elevator lurched into motion, he turned to me and said, “C’mon, smile! It’s not so bad.”

His comment snapped me out of my reverie. I turned my head to look at him and reflexively smiled, though immediately wondered why. His glasses lacked rims and his head lacked hair.

“Are you almost done with your day?” I asked. Maybe he was having a bad day.

He snorted before he glanced at his watch. “Eh… maybe.”

Shift change was in less than 45 minutes.

“Might you have to work mandatory overtime?” The officers I work with often learn of their mandatory overtime shifts about an hour before the next shift begins.

“Ha! No,” the officer laughed. He looked at me again as the elevator reached my floor. “I’ve worked here longer than you’ve been alive.”

Now, in retrospect, I should have let that one go. Maybe he was giving me a compliment: You look young! The sneer in his voice, though, suggested that he wasn’t.

“I think you believe I’m younger than I actually am,” I said over my shoulder as I walked out of the elevator.

“I’ve been working here for 36 years!” he called after me.

“I’m older than that,” I said, without turning my head.

Before the elevator doors slid completely shut, he shouted, “NOT BY MUCH!”

“I’m pretty sure he wouldn’t have said, ‘I’ve worked here longer than you’ve been alive,” if I were a guy,” I complained to my female colleagues.

“Yeah… but, you know, he was right: You’re not much older than 36 years.”

Categories
Lessons Nonfiction Observations Reflection

On Knowing Yourself.

I know of only two people who, upon starting medical school, knew that they wanted to become psychiatrists. (How did they know what they wanted to do eight years before they did it???) They both achieved their professional goals: One created a community clinic for people with severe psychiatric illnesses. The other became an addiction psychiatrist and now oversees an entire substance use disorder program for a health care organization.

I was not one of those people. As a youth, I aimed for family medicine, a generalist that would help people of all ages. While studying microbiology in college, I aimed for infectious diseases: The ingenuity of single-cell organisms! The science behind antibiotics and antiretroviral medications! The elegance of diagnosis and treatment! (My fascination with microbiology persists.) In medical school, I learned that infectious disease is a subspecialty of internal medicine and, WOW, there are a lot of subspecialities within internal medicine! Oncology (cancer) and nephrology (kidneys) captured my attention for a while—more incredible physiology that occurs on a cellular level!—and, then, seemingly out of nowhere, appeared psychiatry.

We’re biased when we look back at how things unfolded: We can’t change the past, so we tell ourselves that it all worked out the way it was supposed to. So, yes, of course I was supposed to go into psychiatry all along.

It became clear during my psychiatric training that I prefer to work with people who are experiencing severe psychiatric symptoms, particularly psychosis (e.g., people who hear voices saying terrible things about them, people who believe that someone has exchanged their internal organs for someone else’s). I also like the intersection and interplay of physical and mental conditions: Sometimes people who have significant medical illness develop striking psychiatric symptoms, which resolve along with their medical illnesses. Sometimes people with significant psychiatric illnesses develop significant medical problems, and successful treatment of both conditions requires teamwork. Complex problems are fascinating. Witnessing people recover from complicated conditions is rewarding. I’m lucky that I have had the opportunities to do this work.

I’ve also recognized that I am not consistently warm and empathic to people who are experiencing mild psychiatric symptoms. Two previous patients come to mind:

  • “I’m so stressed out,” she said while wringing her hands. She began to pick at the tassel of her Coach bag. “I don’t know which to remodel first: The beach house? the pied-a-terre? or the kitchen in our home? It’s all I think about and I’m starting to lose sleep over this.”
  • “My girlfriend started taking Prozac a few months ago, and it seemed to really help her. She has a lot more creativity. I’m thinking it might help me with that, too. In my line of work, creativity is important and if Prozac will help me with that, I won’t feel as much pressure on the job.”

For the woman with the three properties, we worked through that with minimal use of medications. I’m not proud to say that, for the man who desired creativity, I stared at him blankly when he was done speaking.

It’s important to know yourself. As I understand it, it usually takes at least a lifetime to learn about yourself. Even then, most people never know themselves completely by the time they die.

Learning about yourself helps you recognize how you could do things better or differently. We all have our weaknesses. They exist, even if we wish they didn’t. Everyone else sees them, even though we don’t.

There are many ways to get glimpses of our blind spots. If we’re willing to linger a bit when we catch these glimpses, we have the opportunity to make ourselves more awesome.

However, it’s hard to linger because these glimpses often occur when we’re angry or annoyed. Maybe you make an executive decision for something to happen and a lot of people don’t like it. Maybe you learn that not as many people liked or supported you when you thought they did. Maybe you wish that an institution or a group of people would write or say nice things about you, but they don’t.

How it burns!

These are all opportunities to get to know yourself a little better:

  • What emotion am I experiencing?
  • What happened that led me to feel this way?
  • What do I think the truth is?
  • Is it possible that what I think is true isn’t actually true?
  • What questions could I ask to learn more?
  • What do I think might happen if I start to ask questions?
  • What would it mean to show ignorance?
  • What would it mean if I were wrong?

Wherever you go, you bring yourself with you. Even if you do not yet have any interest in learning about youself, that doesn’t stop other people from learning about you. It is much more humiliating when everyone else knows you much better than you know yourself.