Category: Observations

Categories
Observations Seattle Systems

About the CHAZ….

You’ve heard about Seattle’s Capitol Hill Autonomous Zone (CHAZ), right? With free press from President Trump, people both in the US and abroad now know about the “Seattle takeover” and his imperative to “Take back your city NOW”.

Well, dear reader, if you believe that I am reliable narrator, let me share with you my observations of the CHAZ.

First of all, this is how the CHAZ website describes the Capitol Hill Autonomous Zone:

The Capitol Hill Autonomous Zone née “Free Capitol” is a 6 block section around the East Precinct in Seattle, WA. Abandoned by police and left to burn, this area was instead siezed [sic] by anarchists, BLM supporters and other protestors who have since transformed it into a unverisal [sic] community based on mutual aid. Fundamentally, CHAZ is an occupation of Capitol Hill, not an official declaration of independence.

Here’s some context about the Capitol Hill neighborhood where the CHAZ is located: In addition to being the gay mecca of the Pacific Northwest, Capitol Hill is the hip neighborhood of Seattle.[1. Some would comment that Capitol Hill is the hipster, not hip, neighborhood of Seattle.] Bars old and new cater to the spectrum of genders. There’s wood-fired bagel cafe; a bike shop where, after spending time in the physio lab, one can order a Matcha Chicken Avocado Bowl; and a music venue called whose full name includes “Crystal Ball Reading Room”. Two blocks south from the CHAZ is a dealership shared by Ferrari and Maserati. A local cafe offers apricot jam doughnuts for $3.85 each. Rent for a one-bedroom apartment near the CHAZ is around $2000 a month.

Now, onto my observations:

According to the City of Seattle, about 65% of the city population is white and nearly 7% are Black. The vast majority of people (much more than 65%) I saw in the CHAZ were white. Perhaps this was due to the clumps of white tourists who wanted to witness the CHAZ themselves. Maybe white allies had taken upon themselves to “do the work” and use the CHAZ to advocate for Black Lives Matter (BLM) causes and demands. (Of note, I cannot find any comments from the Seattle-King County chapter of BLM about the CHAZ.) Despite the ongoing pandemic, a notable fraction of these white individuals were not wearing face coverings.

While there is a beautiful mural of “Black Lives Matter” physically on Pine Street and references to Black individuals of Seattle and beyond who have been killed by police, the overall vibe of the CHAZ seems more focused on opposing authority. The graffiti on and around the now abandoned police station, the “conversation cafe” stations, and the new community gardens seemed to chiefly cater to white audiences and suggest an anti-establishment philosophy. Black Lives Matter and “a universal community based on mutual aid” are not the same thing, and this is highlighted in the deliberate demands of the Seattle-King County chapter of Black Lives Matter. To be fair, there is overlap between the demands of CHAZ and BLM, though what people do often reveals actual intentions compared to what people say.

In addition to philosophical contrasts, there were physical contrasts within the CHAZ. A man was hugging his adult poodle like a baby, while a crowd of people were nearly running after a man who was yelling at someone about a stolen phone. A white man with what appeared to be a taxidermy weasel draped around his shoulders got into a profane shouting match with a Black man (one of the very few I saw) seated on a bench, a push cart stuffed with belongings next to him.[2. I promise you, dear reader, that there was indeed a man who had draped what appeared to be a taxidermy weasel around his neck. Maybe it was a plush weasel, but the effect was the same.] A (white) man was shoveling wood chips into a new community garden marked with a hand-written sign that read “This garden is for Black and Indigenous folks and their plant allies”. All the doors to the public bathroom were closed and the phrase “shoplift your future back” was scrawled in spray paint on its foundation.

Meanwhile, Seattle Parks and Recreation collected trash from the CHAZ and hauled it away. An employee, wearing a face covering, emerged from a Seattle Public Utilities truck with a clipboard and headed towards the park.

Here are my questions:

Is the Capitol Hill Autonomous Zone a distraction from Black Lives Matter? If yes, what are the consequences of that distraction at local, state, and federal levels, now that President Trump has condemned this “occupation of Capitol Hill”? What are the consequences to BLM if it is conflated with the CHAZ?

Could an Autonomous Zone exist anywhere else in Seattle? Does it matter that this part of Capitol Hill is young, trendy, and expensive? Could the Autonomous Zone exist in a Seattle neighborhood with more Black lives, such as the Central District or Rainier Valley? Even if the Autonomous Zone could exist in another neighborhood, would it exist? Would protestors want that? Would the neighborhood support that?

Has the local chapter of BLM made a statement about CHAZ? If yes, why is it difficult to find? If no, what worries or hopes does BLM have about doing so? The Seattle-King County BLM chapter has demonstrated great thoughtfulness about its activities in the midst of this pandemic, including specific rules about their protest. Their silent march drew around 60,000 protestors despite the rain. I look forward to learning more about and supporting their perspectives.

Will the CHAZ protestors vote? Some argue that the only way to change the system is to join it. Others insist that change can only come from the outside, as there are too many conflicting interests from within. Voting applies in either scenario.

Will the CHAZ protestors follow the lead of BLM? Sometimes the urge to “do something” is overwhelming, when the most productive and helpful action is to wait and follow. Before people congratulate themselves on the actions they are taking, it is prudent to ensure that these actions are in the service of the goal that will both change and improve the system.

How will the CHAZ end? Will the protestors leave of their own accord? Will they stay until forced to leave? Will there be non-violent negotiations, or will we witness more violence? How much effort will Seattle Police put into returning to their precinct building? What is the Mayor’s strategy about this, now that she is the target of antagonizing messages from both Seattle residents and the President of the United States?

When will the CHAZ end? With unemployment rates high in Seattle, as in the rest of the nation, some people may choose to remain in the CHAZ because the economy continues its slump. There is a Presidential election in November and if the President continues to give his attention to the CHAZ, that may reinforce their desire to remain. If Seattle sees a spike in coronavirus cases, will the city recruit Public Health to help assess the safety of the encampments and gatherings and then ask people to leave?

If you live in the Seattle-King County area and are able, please donate money to the Seattle-King County chapter of Black Lives Matter. Whether you live in Seattle or elsewhere, please also participate in the US Census and make sure you vote in the upcoming elections. Please continue to ask questions, engage your mind, and exercise critical thinking. Change will take all of us.

Categories
COVID-19 Homelessness Medicine Nonfiction Observations Policy Seattle

The Space Between Us.

I am one of the few people walking through downtown Seattle these days. Most of the people outside are people who slept outside the night before. Sometimes they are still sleeping in sleeping bags or tattered boxes when I walk past. They’ve always been there, but now that there are much fewer people outside, they seem to be everywhere.

The other people walking through downtown in the morning fall into two groups: People going to work, like me, and people walking their dogs. The people out and about in the morning are much more likely to wear face masks. The evening crowd seems to be younger and they are much less likely to wear face masks.

I see the magnolia trees bloom. Their pastel petals are already falling off to make room for new leaves. The soft pink cherry blossoms are already gone; the tree limbs are already full of fresh green leaves.

The offices now have bottles of liquid hand sanitizer from local distilleries. The hand sanitizer coming out of the wall dispensers have floral and chemical notes.

Every staff person should have their own set of cloth face masks. There are two in a bag. Volunteers sewed and packaged them. One of mine is dark blue with intersecting white lines. The other is light blue with a large pattern that is reminiscent of paisley.

Several people staying in our shelters have tested positive for coronavirus. There haven’t been “clusters” of cases yet, just one here, another one there. Staff show up to work, don their cloth face masks, put on gloves, and wipe down surfaces with disinfectant when they can. Some people staying in shelters cough and sneeze. Most put on the surgical face masks that staff give to them and try to stay away from other people, but where are they to go? A few are unable or unwilling to wear face masks. Staff continue to don their cloth face masks, put on gloves, and wipe down surfaces.

People are moving from congregate shelter settings into motel and hotel rooms. What will happen when people have their own private spaces? Their own bathrooms, their own beds, their own doors that they can lock? This reduces the likelihood of disease transmission. What else does this reduce? Hypervigilance? Paranoia? Pain? Substance use? (Or maybe it increases all of those things?)

The nurses are amazing. They try to assess for respiratory symptoms from six feet away, a subtle dance that we’ve all had to learn how to do quickly. Maybe it’s a chronic cough. Maybe it’s flu-like symptoms. Maybe it’s coronavirus.

The internal coronavirus team is amazing. They organize the waterfall of data and quickly refer people to the county isolation and quarantine sites. The system has started to move faster, but it’s not fast enough. And what are we to do when the isolation and quarantine sites won’t accept our referrals? Who holds the balance between liability and public health? What will the emergency departments say when it is the fear of acute withdrawal, not the actual withdrawal itself, that results in a visit from someone with coronavirus?

When I start feeling angry, I pause and realize that my colleagues in hospitals have even more reasons to feel anger. I’m not misreading the guidance: Following a high risk exposure to someone with confirmed coronavirus, staff should continue to work even if asymptomatic. Of course, I know why: The system needs health care workers to work during this pandemic. But what is the message this sends to individual workers? You might get sick, you might contribute to asymptomatic spread at work. The people who live with you might get sick. Despite this worry for yourself and those around you, please continue to work. And because we don’t have enough tests right now, we won’t test you until you start to demonstrate symptoms.

(What about the grocery store workers and farm workers? Do their employers provide face masks? Are they part of unions? Do they have health insurance?)

You are essential, you are a critical worker, you are immune to worry and anxiety. Right? This is no time to worry about yourself because we also don’t have time to worry about you.

I see the pairs of police officers leaning against their cars on Pike and Pine, their arms crossed. The sun stretches its warm rays across the sound and the new leaves rustle in the spring breeze. My cloth mask is mildly damp from the humidified air moving in and out of my lungs. I make brief eye contact with the person approaching me. We make time to worry about each other and the physical space between us grows.

Categories
COVID-19 Nonfiction Observations Seattle

Spacious in Seattle.

Downtown Seattle isn’t completely empty, but there is suddenly more space. Buses zoom by, though they carry few passengers. Rush hour traffic is a faint memory as cars speed along the avenues. Instead of weaving my way through crowds of people, I now have meters of sidewalk all to myself.

I went on a cookie break this afternoon. The sole employee in the cookie shop saw me pause at the front door while I read the sign: “Express window is open”. From inside, she beckoned me to walk three meters to the right, and when I arrived at the window, she slid it open.

“Hi.”

“Hi. Do you have day-olds?”

“Yes, right here.” She waved a gloved hand over the small basket sitting just inside the window. Cookies, stacked three high, were wrapped tightly in saran wrap. I selected a standard chocolate chip stack and a double chocolate stack.

While we waited for the credit card reader, we talked about these extraordinary times.

“Thanks for providing cookies to those of us who are working.”

“Thank you for buying them!”

“Yes, I’m glad that this shop is open. At least we have jobs.”

She nodded vigorously, then added, “Yeah, we are lucky.”

About an hour earlier, I asked one of the younger nurses at the agency how she was doing. She said that she was doing okay, then shared that she was grateful that she still had a job. She grimaced while she shared this anecdote: “Have you heard of This Fancy Restaurant? They laid off all of their staff on the same day. They can’t even collect unemployment.”

After tucking the two stacks of cookies into my coat, I saw this:

handwash

The restaurant serves a type of Asian cuisine. The man behind the counter was helping a customer, so I didn’t go in to thank him. Had I done so, I think I would’ve started crying.

Categories
Medicine Nonfiction Observations Reflection

Work Spouses and Mentors.

I recently had dinner with a good friend. He and I trained together at the same time and he has since gone on to become a super fancy academic psychologist on the East Coast. Over dinner, he opined that an optimal work situation includes two components: a “work spouse”, and a mentor.

“The work spouse is at the same level as you—same training, same work,” he said between bites of lasagna. “And a mentor is a mentor.”

“Yes!” I exclaimed. My mind recalled the respect and affection I had for all of my “work spouses” over the years:

  • Chris and Sohan both made me laugh, helped me with the endless scutwork to get me out of the hospital, and helped me keep things in perspective when we were interns.
  • Ryan, Scott, and Ryan also made me laugh, provided thoughtful clinical consultation, and gave sage personal advice while we became less human during residency. There was even that time when we were all on call on the same night, but at different sites… and we called each other sometime between 3am and 4am just to check in. Ryan and Scott also taught me how to throw a football; the other Ryan taught me how to improve my storytelling.
  • Sharon made me laugh during fellowship (do we see a theme here?) and provided an international perspective about community psychiatry. Sharon and her husband also invited me to experience a Passover Seder.
  • Joe made me laugh (…) and helped me cope with the stress and discomfort of 15-minute medication appointments. He also validated my opinion that such a model neither matched my values nor allowed me to provide the care that I believe people deserve.
  • Craig also made me laugh, helped me think through difficult clinical quandaries, and also validated the privileges and challenges associated with working in a jail.

In two cases I didn’t have a “work spouse”. They were both medical director positions… and in both instances I was the only physician who worked in those parts of the organizations. Let me be the not-first to say that, yes, doctors think about and approach things differently. Sometimes it’s useful; sometimes it annoys the heck out of everyone else. It’s often isolating: On the one hand, sometimes people elevate an opinion simply because it comes from a doctor; on the other hand, sometimes people disregard an opinion because the doctor’s perspective seems irrelevant. Both reactions are problematic.

“I haven’t had a mentor in years,” I said after a long pause. “Maybe that’s because there aren’t a lot of Asian women who work in public sector psychiatry?”

That might be true, but I don’t know that for sure (though, as I have progressed in my career, it seems that there are few psychiatrists who choose to work in public sector, non-hospital, non-clinic settings). My mind ran through the people I have considered mentors:

  • Randall, a gastroenterologist, taught me in medical school how to remember that patients are people.
  • James, a psychiatrist, highlighted the intellectual rewards of psychiatry and is arguably the person who persuaded me to pursue a career in psychiatry instead of internal medicine.
  • Matthew, an infection disease physician who longtime readers recognize at the Special Attending, demonstrated the intellect, kindness, and humanity that we want our doctors to possess. He was one of the few attendings I worked with who brought cold water and warm blankets to patients when they requested them.
  • Dick, a pharmacist, not only knew a ton about medications, but also dispensed Taoist wisdom about how to manage people in distress… including ourselves.
  • Deb, a psychiatry residency program director, demonstrated a steady grace and cool serenity despite the tumult of resident distress. I still recall and admire her steady support and faith.
  • Brad, a psychiatrist, taught me that “patients are called patients because they are patient with us” and that, while we have the privilege of helping people, we should discard any “rescue fantasies”. The true heroes are the patients, not us.
  • Sarah, a psychiatrist who worked as a medical director for a major US city, validated my interest in working at the boundaries of fields and also encouraged me to apply for positions that I thought were out of my league. “If something scares you, you should do it.”
  • Van, the only boss I’ve had who is both a psychiatrist an a person of color, continues to provide sage career advice and said that words, “Everyone should receive high quality psychiatric care, whether they go to a nice office on Park Avenue or if they sleep on a bench.” Just knowing that someone else thinks that makes me feel less lonely.

At the risk of sounding woo-woo, though, we can all find mentorship everyday. Everyone can be our teachers if we are willing to be students. I think about the bus driver who greets everyone with a warm smile, but has no qualms about commanding—firmly, but politely—a rider to stop harassing vulnerable people who are also on the bus. Consider the finance officer with no formal authority who speaks up during a meeting to advocate for more transparency in fiscal affairs. What about that coworker who picks up the litter in the lobby when he thinks no one is watching? Because he wants to leave a place looking better than it did when he walked in?

If you are fortunate to have a work spouse, bring him or her a treat. If you don’t think you have a mentor, remember that there are others who can provide guidance and inspiration.

Categories
Consult-Liaison Education Medicine Observations Reading

Hoping for Hope for Psychosis.

The American Board of Psychiatry and Neurology (ABPN) is running a pilot project: Psychiatrists and neurologists can read a set of articles and answer mini-quizzes over the course of a year instead of taking a multiple-choice exam. If the physician answers enough questions correctly in either activity, then this supports the application for board recertification.[1. To be clear, I feel frustration with the American Board of Psychiatry and Neurology and their board recertification procedures. This “read articles and take mini-quizzes” is an encouraging improvement, but there are other aspects of board recertification that give me heartburn. This is why I am also a member of the National Board of Physicians and Surgeons.]

I am enrolled in the “read articles and take mini-quizzes” pilot. One of the mandated articles is “Improving outcomes of first-episode psychosis: an overview“. One of my professional interests is psychotic disorders (e.g., conditions wherein people report hearing voices and beliefs that do not appear rooted in reality). If you share that interest, you may find this article informative, too.

Note I said “informative”, not “encouraging”. Here are a selection of statements I found notable in the article:

Psychotic disorders such as schizophrenia are common, with 23.6 million prevalent cases worldwide in 2013. One in two people living with schizophrenia does not receive care for the condition. The recovery rates… and associated disability… following a first episode of psychosis have not improved over the past seventy years under routine clinical care. Although existing psychopharmacological treatments alone can reduce some symptoms, they have little impact on the outcome of the illness.

Oof. This is the first paragraph of the article! None of the statements surprise me, but when they are all put together like that… well, it makes me wonder: “When are we going to get better at this? When will we consistently help individuals with these conditions?”

At the moment, there are no approved [prevention interventions for individuals who are clinical high risk for psychosis] that have been shown to reliably alter the long-term course of the disorder.

Sigh. This speaks to population-level data. This means that we—the individual at high risk, the family and friends of this person, and any professionals involved at the time, if we happen to meet this person—grope around as we try to minimize the risk of illness. Maybe our efforts will work for This Person, but maybe they won’t for That Person. So we continue to work and hope.

The detrimental impact of illicit substance abuse on the long-term outcome of psychosis is well known, with a dose-dependent association.

Here in Washington State, we see a lot of people with psychotic symptoms who have used or are using methamphetamine. It ruins minds. I wish people would stop smoking/snorting/injecting it.

Marijuana is legal in this state and there is some evidence that cannabidiol (CBD), a compound found in marijuana, may reduce psychotic symptoms. Delta-9-tetrahydrocannabinol (THC), also found in marijuana, can induce psychotic symptoms. This is problematic. Companies sell CBD on the internet and I have concerns about how people will run with this preliminary data.

[There is a] lack of stringent evidence for a robust effect of antipsychotics on relapse prevention in the long term….

The article summarizes evidence that suggests that antipsychotic medications may simply delay the relapse of psychotic symptoms, rather than prevent them from reappearing.

One of my early jobs was working in a geriatric adult home. My work there taught me that people with psychotic disorders can and do get better. The burdens of antipsychotic medications—paying for medications, the actual act of swallowing the pills every day, the side effects, some mild, some intense—add up. I was fortunate to work with some people to successfully reduce the doses of their antipsychotic medications and, in some cases, stop them completely! (There were also at least one instance when tapering medications was absolutely the wrong thing to do; that person ended up in the hospital. I felt terrible.)

When I reflect on that time, there were no guidelines about this. These decisions to taper medications—always with ongoing discussion and with the individual’s consent—were just an effort to “first, do no harm”. Context matters: I used as much data—from the individual, family and caregivers, and the literature—as I could find before embarking on deprescribing. Was I naive and reckless? Maybe. Was I just lucky? Maybe? Was I doing the best that I could with the information I had? I think so.

Schizophrenia features are strong predictors of poor long-term outcomes… when communicating with patients, it may be preferable to use the broader term psychosis rather than schizophrenia….

As far as I know, schizophrenia is the only psychiatric diagnosis that includes the criterion “Level of functioning… is markedly below the level achieved prior to the onset“. Even the neurocognitive disorders (dementias) don’t explicitly comment on a decline of “level of functioning”.

One wonders if the long-term outcomes in schizophrenia might be even just a little bit better if those of us who give the diagnosis of schizophrenia believed that people with this condition could get better. Do we, as a group, give this diagnosis out of resignation? And what message does that send to individuals experiencing these symptoms?

And what about that recommendation that we don’t discuss “schizophrenia” with individuals with psychotic symptoms? Indeed, for individuals presenting with “first episode psychosis”, this counsel is prudent. People with psychosis do get better. But, again, do we avoid using the term “schizophrenia” because of the connotations associated with that word? “… we don’t think you will ever get better.”

Maybe this is a circular argument: The reason why a decline in function is part of the definition of schizophrenia is because there is a decline in function in people diagnosed with schizophrenia.

But what about the people who meet all criteria for schizophrenia who get better?

The people who discern the pathophysiology of schizophrenia shall win the Noble Prize, for they will have figured out how the brain works. And perhaps, by that time, the articles about psychosis will give us all hope.