Categories
Nonfiction NYC Observations

Lunch.

During my first year in New York, I packed my lunches in plastic grocery bags from Morton Williams. That is where I purchased cartons of frozen Shop Rite veggies, picked through Cortland apples, saw packages for matzoh ball soup, and overheard elderly women bicker with cashiers over the price of the deli pasta salad.

My lunches were simple: thin sandwiches, leftover pasta and vegetables, string cheese, fruit, nuts. If I wanted a treat, I’d slip in a few cookies.

Upon sitting down at the round table in the office next to the large windows overlooking the East River, I unwrapped my lunch. Several of the attending psychiatrists showed great interest in my food.[1. I have never before nor since experienced so much fascination from others about my lunches.]

“So… what did Dr. Yang bring for lunch today?

“What homemade goodness are you having?”

Sometimes they stood over me; sometimes they pulled a chair out and sat down, leaning forward to inspect the contents of my lunch.

“What’s in that? Eggplants? Tomatoes? I smell garlic.”

“What kind of apple is that?”

“Leftover pizza, right?”

As I confirmed or otherwise explained the ingredients in my lunch, sometimes they congratulated each other for their discernment. I nodded and resumed eating. They wandered away towards the door.

“So… diner?”

“It’ll be crowded. How about the cart out front?”

“The diner is always crowded, but they make good fries.”

“Okay, the diner it is.”

The team nurse often entered the office after the psychiatrists had left. She spoke with a Brooklyn accent, dressed with class, and carried herself with confidence. Though the wrinkles around her eyes and on her hands revealed her age, she argued with vigor when she disagreed with the director of the service. He would persist, though knew to relent: She was a strong woman.

Sometimes, upon finding me eating alone, she would sit down at the table. She shared history about the department, interesting developments in other parts of the hospital, and updates about patients I had seen.

She also shared her sadness about her son. He was killed while serving in the military a few years prior and the anniversary of his death had just passed. Though she was smiling, her eyes were already full of tears. Her voice cracked as she apologized for crying.

“I miss him so much,” she said, dabbing her eyes with a ball of tissue. As she pulled apart the ball, she murmured, “My mascara is starting to run, isn’t it.” More sad than annoyed, she motioned me to walk with her to her desk. Her computer wallpaper was a photo of her son in his military uniform.

She pulled out a compact and examined her eyes, wiping away the trails of diluted mascara on her cheeks. She was still crying.

The sky was dark. A storm was coming. The arcs of the grey clouds were descending upon the lines of the housing projects and warehouses across the river. Her screensaver began flashing photos of her dead son.

The office door opened; the psychiatrists were back from lunch. The nurse quickly wiped her nose and forced a smile.

“Time to get back to work,” she said, standing up.


Categories
Nonfiction NYC Observations

East 77th Street.

I was standing on the south side of East 77th Street near York Avenue. It was late June and my first night living in New York City. Everything I owned—two bags full of clothes and shoes, travel-sized toiletries, two towels, a disassembled table, a bed, one pot, a laptop computer, and important documents—was in a pile on the sidewalk.

I hadn’t wanted to live that far from the hospital. The broker—tan, fit, and preoccupied—glanced at my documents[1. Formal brokers in New York City commonly want two pay stubs, your most recent tax return, and proof that you have a bank account before renting you an apartment.] and said, “You can’t afford to live near the hospital. But you could live on the Upper East Side. You could take the 6 or the M15 to work.”

Rents increased the closer the apartments were to the subway. I couldn’t afford anything beyond 1st Avenue.

My apartment was a “cozy” studio on the first floor. It was in a red brick tenement, built around 1940, that was four stories tall. White, vertical metal bars adorned the inside of the single window. Jutting out underneath was a rumbling window air conditioner.

There was also a small window in the bathroom that opened to a small, dark enclosure that was littered with cigarette butts and dented soda cans. When that window was open, the aromas of cooking food, the shouts and cursing of people watching football games, and the moaning of men and women having sex often floated in.

The kitchen had a two-burner stove, a miniature oven, and a short fridge. The sink was metal and shallow. There was no room for a table.

The main living space was just large enough for a full-sized bed and a small desk. I got the desk from the man I was dating. It was an old table, constructed of particle board, that he was going to throw out. The tabletop was white and visibly sagging; it resembled a hammock on four rusting legs. I eventually got a small bookshelf. To get to the window, I had to squeeze myself between the bookshelf and the foot of the bed.

The apartment was probably around 250 square feet. Rent was $1550 a month.

Before I learned that the heating pipe in the corner would often clang as the radiator overheated my apartment all winter, that, in this neighborhood, black women often pushed baby carriages holding white infants, that people would fish from the East River before 6am, that lights in the Empire State Building could change color, that up to 1000 people would pour out of Penn Station every 90 seconds[2. “… Penn Station, which is the busiest station in North America, funnelling 600,000 passengers through just 21 tracks, sometimes at the rate of 1,000 people every 90 seconds.”], that my then boyfriend and I would eventually get married in Central Park, before all that–

–I stood on the sidewalk on East 77th Street and looked around. People ignored me and walked around my pile of stuff. Yellow taxis, black Lincoln town cars, and men on bicycles delivering food rolled along York Avenue. Only a few stars dotted the indigo-charcoal sky.

I had a place to live, a new job that would start in a few days, and at least a year to learn about and live in New York City.

I grinned.


Categories
Nonfiction NYC Observations

Running Along the East River.

While organizing some files on my computer, I came across some of my old writings. The following was undated, but I suspect that I wrote it sometime during my first summer in New York City. I was living on the Upper East Side.

The first sentence of the piece describes the experience of running along the East River. The last sentence is still true.


The smells of salt water muck and car exhaust enveloped me. My nose crinkled involuntarily and I felt my diaphragm resist a full, deep breath: The air smelled noxious.

This will pass, I reminded myself. I had encountered into the same malodorous swirl during the first half of my run; Pig Pen’s cloud hadn’t accompanied me the entire way.

It was only 5:30am, but the temperature was already near 80 degrees. In addition to smelling like a polluted lake, the air was heavy and thick with moisture. I felt like I was breathing through a soggy, soiled wool sock. My running shirt and shorts, which had wicked sweat so effectively from my skin in Seattle, were now clinging to my damp skin like that last noodle lingering in the almost soupless bowl.

I was not sweating alone, though; other residents humans and dogs in New York were watching the sky alight with the morning sun. A few other runners plodded along; several couples walked hand in hand; cyclists sans helmets zipped past. Several individuals in various states of undress occupied benches. Some had slept there all night. Some were watching the sky, as if waiting for a celestial message.

Encouraging myself to actually smell the air, I took in a breath, timing my respirations with my footfalls. My eyes focused on a bench about thirty yards away: You can make it to that bench.

I had noticed him during the first half of my run. His arm was slung around the slender shoulders of the young woman leaning up against him.

Now, he had risen from the park bench, leaving his faceless sweetheart behind. I noticed him noticing me. He noticed me noticing him. I saw the impish smile form on his face.

When I passed him, he began to run and, within a few steps, was running alongside me. As he approached, I instinctively began to run faster out of alarm, though it was soon seemed that his intentions, though unclear, were probably not malicious.

(… though one never really knows for sure.)

“This is hard,” he commented in a Middle Eastern accent. His loose pant legs rustled against each other as he tried to maintain my pace.

“This is true,” I replied between breaths, playing along. A random stranger just started to run with me at 5:30am in New York City.

He smiled again and mumbled, “How do you do this?” before decelerating. He was soon walking and, presumably, returned to the park bench and the object of his previous affections.

I passed the bench that I had mentally marked earlier and selected the black gate that was about forty yards ahead.

I don’t know. Though I do know that none of this would have ever happened in Seattle.

Categories
Homelessness NYC Observations

Memorial.

Two weeks had passed before I learned what happened.

I hadn’t seen him in several months. At our last meeting, the trees were full of red and orange leaves. He, as usual, was not interested in talking to me. He was sitting in front of a closed shop.

“Hi. How are you?”

“Fine.”

People in the neighborhood took care of him. Surrounding him were several plastic bags holding neatly stacked styrofoam containers filled with soup. Another bag held several pastries, most of them still wrapped in clear cellophane. Another bag contained many empty, crushed water bottles.

“Anything new happening?”

“No.”

He was old enough to be my father, though he looked like he could be a grandfather. Time had taken away some of his teeth. The joints of his fingers were knobby. Crescents of dirt were caked underneath his nails. He was wearing a different coat.

“You got a new coat.”

“Yes.”

He previously wore a blue windbreaker; now he was wearing a puffy black jacket that was three sizes too big for him. His thin neck poked out above the collar. The jacket was unzipped and showed the soiled white tee shirt he wore underneath.

“Any more thoughts about going inside for the winter?”

“Not now.”

People were starting to gather around us. In that particular neighborhood, passersby routinely stopped and gawked whenever I spoke with people who appeared obviously homeless. They were staring at us, their mouths hanging open, their faces perplexed.

“Can I help you?” I barked at them, doing nothing to mask the irritation in my voice.

In response, they closed their mouths, turned away, and walked on. (Related: One of the fastest ways to get people in New York to stop looking at you is to say, “Hello!”)

“Where are you sleeping now?”

“In the park.”

Sometimes he slept in a box. He usually slept on a flattened box, and it often wasn’t in the park. People had seen him underneath nearby construction scaffolding. Others saw him in the subway station, though he didn’t seem to use the subways at all.

He said that he had been outside for “a while”. Records from the shelter and from concerned citizens in the neighborhood suggested that he had been outside for at least 20 years.

“I know you’ve heard this before, but just humor me: You don’t have to stay outside. You can stay in a small studio apartment where they serve two meals a day, you can store your belongings there—”

“I’m okay.”

I felt for him. I wouldn’t want to talk to me if I were him.

When homeless people disappear from their usual locations, I wonder: Have they moved to a different neighborhood? Were they arrested and now in jail? Did they find a place to live? Are they in a hospital?

I often never find out.

This man had died. He contracted pneumonia and was in an intensive care unit for about a week. Was there a code? Did the physicians withdraw care? If so, who made that decision? Was anyone with him when he died?

There was no funeral. There was no memorial. Did anyone from the neighborhood notice that he was gone? Did any of those people who gawked at us notice his absence? Did people assume that he ultimately agreed to go into housing, that he finally changed his mind?

Did anyone think that he had died? Did anyone miss him?

Categories
Education Homelessness Informal-curriculum Lessons Medicine NYC Observations Policy PPOH

Supervision and Support.

To conclude a description of my previous job at PPOH in New York, let me tell you about Friday afternoons.

Every Friday afternoon, the staff psychiatrists met as a group for three hours.

Those three hours were important and valuable. During that time, a variety of activities occurred:

Case presentations. Different psychiatrists presented cases to solicit ideas and help. Hearing the thoughts of others provided fresh perspectives and helped us “think outside of the box”. Each psychiatrist had his specific strengths and this forum allowed us to access his expertise.

Example: Someone once presented a case about a woman who was refusing to accept treatment for a major medical problem. The psychiatrist had assessed her decisional capacity and it appeared intact. This meant that we—other doctors, her psychiatrist, other non-medical staff members—had to respect her wishes… and also watch her become more ill and eventually die. The psychiatrist who presented this case wanted to (1) ensure that his assessment of her decisional capacity was thorough, (2) learn how to manage the (often angry and frustrated) reactions of the other physicians and non-medical staff, (3) get ideas about how to coach the other physicians involved in the patient’s care when they wanted to do something and she refused, and (4) vent and get support from us, as managing his own reactions and the reactions of others was taxing.

Sometimes the case presentations were less complicated: How can I encourage this patient to try medication? Is there anything I can do to get this patient to stop asking for medication? Do you have any ideas as to how we can keep this guy out of the hospital?

Grand Rounds. Grand rounds refers to a lecture on a specific medical topic. It is often considered a “big event” (i.e. lots of people are invited or expected to go). In academic medical centers, someone well-known in the subject usually gives the lecture.

PPOH established a Grand Rounds committee[1. The PPOH Grand Rounds committee was comprised of two people: a senior PPOH psychiatrist and me, as we were both interested in medical education. If you would like me to speak at your Grand Rounds or provide other teaching, let me know.] to organize a series related to homelessness and mental health. Speakers with expertise on schizophrenia, common infections in the homeless, harm reduction, housing first, tobacco use and cessation, and other topics shared their knowledge with us.

These lectures were an essential part of continuing medical education. We need and want to learn so we can provide excellent care for our patients, particularly since there is a dearth of literature for this population.

Peer supervision/support. Every job has its challenges. In psychiatry, it is no different. Working with individuals who have significant mental health problems, homeless or not, can be stressful. Sometimes we feel anger towards patients. Sometimes we feel frustration with other psychiatrists or physicians. Sometimes we feel scared that we did something wrong. Sometimes we worry that our patients will die.

Much of psychiatric training uses the apprenticeship model. While in residency, we meet with “supervisors” (attending psychiatrists) on a regular basis. Supervisors provide coaching and guidance to help residents learn psychotherapy and prescribing practices. This is also where the informal curriculum is taught: Supervisors are essential in teaching (demonstrating) professionalism and attitudes. It is during supervision that we also learn to examine our own reactions to clinical encounters… and, oftentimes, our reactions tell us more about ourselves than about our patients.

I was deeply grateful for these weekly three-hour meetings. (I have since realized that this set-up is rare. No money is gained while physicians are meeting for supervision. Neither patients nor insurance companies are billed. From a financial standpoint, it is wasted time. However, I’d like to think that this investment in physicians ultimately provides benefits for patients. I don’t know if there is any data to support this, though I believe it is absolutely true.) The built-in network of peers gave me security: I knew I could trust them to help me become a better doctor.

Many medical students and residents feel embarrassed to ask questions. They might feel ashamed to say “I don’t know”. With time and experience, that shame goes away. It’s okay if you don’t know. What you do next is what matters: If you need help, ask for it. You will (re)learn something, you will take better care of your patients, and you can then help another doctor in the future.