Category: NYC

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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.

Categories
Education Lessons NYC Policy PPOH

Assertive Community Treatment.

While at PPOH, I spent two days a week working with an Assertive Community Treatment (ACT) team.

ACT is somewhat like a psychiatric hospital outside of a hospital. It is an evidence-based practice[1. From the New York State Office of Mental Health: “When comparing recipients before and after receiving ACT services, studies have shown ACT recipients experience greater reductions in psychiatric hospitalization rates, emergency room visits and higher levels of housing stability after receiving ACT services. Research has also shown that ACT is more satisfactory to recipients and their families and is no more expensive than other types of community-based care.”] that features a multidisciplinary team (social workers, psychologists, psychiatrists, nurses, case workers) that works with a small group of patients who often experience impairing psychiatric symptoms. It provides comprehensive and flexible psychiatric services. All of the care occurs in the community.

The ACT team I worked on was staffed with:

  • one program director (social worker)
  • one team leader (social worker)
  • one MICA (“mental illness and chemical addiction”) specialist (social worker)
  • one vocational specialist (social worker)
  • one entitlements specialist (almost-graduate from social work school)
  • two case workers (one who had recently earned a social work degree)
  • one registered nurse
  • one secretary (who did much more than clerical work)
  • two psychiatrists (our combined hours did not fill a full-time position)

During my time there, I provided care for about 35 patients. (The other psychiatrist provided care for the other 35 patients.) The staff to patient ratio is purposely kept low, as ACT is considered an intensive intervention.

Patients who are referred for ACT services must have been psychiatrically hospitalized (often involuntarily) at least four times in the past year. They often have multiple emergency room or mobile crisis visits. Other outpatient services have often failed or have been insufficient to prevent crises and hospitalizations.

Thus, a chief goal of ACT is to keep people out of the hospital.

The ACT model dictates that the team (as a whole) must make a total of at least six contacts with each client[2. There is a movement in mental health—and in other parts of medicine—to move away from the term “patient”. In this particular ACT setting, patients were called “clients”. Sometimes they are called “consumers”.] every month, preferably in the community. One of these visits should be a meeting with the psychiatrist. Some patients regularly came to the office for their visits. Others, however, could not or would not come in. We thus went out to them. (Hence the adjective “assertive”, which, in some cases, could be construed as “coercive”. More about coercion later.)

If I did not see patients in the office, I often saw them in their apartments. (Limits and boundaries do not blur, but they certainly shift. My experiences in these residential settings inspired this post. To be clear, there were a few individuals who I never met alone. I insisted they meet me outside or in the clinic. Some of this was due to their past behaviors; some of this was my gut instinct.) For those who did not feel comfortable meeting in their apartments, we met in lobbies, parks, or chatted during walks. (During my time on ACT, I came to value talking and walking as a therapeutic intervention.)

ACT was formerly deemed “long term care”; some patients have been on ACT teams for over a decade. (This is often due to repeated psychiatric hospitalizations despite ACT services.) Most of the patients had psychotic disorders (such as schizophrenia) and, surprisingly, many of them had actively involved family members. I suspect that this impacted who was referred to ACT; family members were often the ones bringing people to the hospital for care (versus calling the police, etc.) Most patients “graduate” from ACT within a few years: They stay out of the hospital, become more involved in the community, and no longer need that level of care.

I learned in this position that people with chronic psychotic disorders can get better. Their symptoms decrease. They learn how to temper their behavior so that they do not attract undue attention while out in the community. They set and reach personal goals, like earning high school and college degrees, securing employment, getting sober from alcohol and drugs, and taking care of their physical health. They stop smoking! Sometimes they need a lot of support and a number of years need to pass before things settle down, but people with diagnoses of schizophrenia are not doomed to a life of poverty and “low function”.[3. The public rarely hears about positive outcomes for people with schizophrenia. There is research that suggests that a significant number of people with diagnoses of schizophrenia either experience improvement or recovery of their condition. Anecdotally, I agree.]

I also learned the importance of seeing patients in their environments. So much of contemporary medicine now occurs outside of a person’s living situation. That is often appropriate and fair (e.g. patients shouldn’t undergo surgery in their own homes). Because of the intimate nature of medicine, meeting in a “third” location can help preserve privacy and security. However, we can learn so much about how people function (or do not function) when we see their living spaces. We also realize strengths that we would otherwise overlook. A neat home, a sack full of old prescription pills, vinyl records of classical music, papers all over the floor, photographs of friends and family, roaches climbing over dozens of empty cans of soda: All of that is information that doctors often never have.

It is amazing how people live their lives. It is remarkable how much people will tolerate. And it is humbling that people are willing to share their lives with you.