Category: Observations

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Nonfiction Observations Seattle

White Glove Treatment.

In addition to five-star accommodations and world-class spa appointments in Portland and Seattle, each [Lamborghini] owner and their guests will be treated to private meals along the Pacific Coastline and the Puget Sound. Expect white glove treatment at every encounter, and curated excursions exclusive to Giro and the region. – GIRO 2017 PNW

The first Lamborghini I saw pulling out of the driveway of the parking garage in downtown Seattle was either yellow or orange. Its engine rumbled for all to hear even though it was in low gear. I stopped walking when I reached the driveway, waiting for the sleek and shiny car to pull into the street.

A few moments passed and another Lamborghini pulled out of the parking garage into the driveway. This one, another bright color, didn’t even stop before it turned left into the street.

The pedestrian waiting on the other side of the driveway was dressed for work: Short-sleeved summer blouse, pencil skirt, dark flats, and bangles on her left wrist. She shifted her weight to her right hip and looked into the garage.

A third Lamborghini zoomed out of the parking garage and swerved left into the street. There were now three or four pedestrians on the other side of the driveway waiting to cross the entrance of the parking garage.

In the street were two women, probably no older than 25, who were wearing white polo shirts and denim shorts. With some anxiety they looked down the street, watching for oncoming traffic. They waved their hands at the garage, beckoning more cars to come forth. They ignored the pedestrians on the sidewalk.

The fourth Lamborghini had a mirrored surface. The morning sunlight gleamed off of its sides. The driver was an older man who was losing his hair. In the passenger seat was an older woman with bright yellow hair and sunglasses that covered half of her russet face. This mirrored car coasted out of the driveway without pausing.

“Oh, come on,” I muttered. The Woman Dressed for Work on the other side of the driveway rolled her eyes and heaved a sigh that was seen, not heard.

More Lamborghinis poured out of the parking garage, parting the Red Sea of pedestrians. The traffic light farther up the street was still red, though, so the parade of Lamborghinis was slowing to a halt in a single queue.

Yet another Lamborghini was approaching the exit of the parking garage. Empowered by annoyance and self-righteousness, I walked forward. Would the Lamborghini let me, a mere pedestrian, have the right of way?

The pedestrians on the other side of the driveway followed suit. The fancy car lurched to a halt as we foot commuters walked in front of it. We all heard the loud, idling engines of more Lamborghinis in the garage waiting for us to pass. Even though some pedestrians slowed their gait, everyone looked straight ahead.

Good manners go a long way. Status alone doesn’t earn white glove treatment and respect.

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Observations Reflection

It’s Okay to Get Angry.

It was my first job as a physician. I was 32 years old.

In that job I functioned as a psychiatric consultant. Thus, while I had clinical expertise, I didn’t have formal authority at any of the places I worked.

I can’t remember now what exactly happened: Someone said or did something that vexed me. It made me worry about how staff might (mis)treat patients. But who was I? I didn’t work for that agency; I was only there two days a week.

“I don’t feel like I can say anything,” I sighed to my boss.

My boss took a sip from his drink and leaned forward on the table.

“Maria, it’s okay get angry,” he said. “Sometimes you need to let people know that you’re angry.”

When we’re young, we often don’t believe that we can contain our anger. And, in some ways, that’s true: We don’t contain our anger because it is unfamiliar to us. There are different flavors of anger: Sometimes it simmers just beneath the surface of our skin while the flames roar in our ears. Sometimes it explodes and tears, words, and fists fly from of our bodies. When we’re young, these flavors are novel and strange: What is happening? What am I supposed to do with this? It’s empowering and overwhelming and frightening all at the same time.

We also don’t believe that we can contain our anger because we often don’t know how. It’s a skills deficit. Our anger propels us to do different things because anger is uncomfortable. We say (or scream) things. We break things. We cry. We bury it within us. We focus the energy of anger into other things. We avoid it.

As we age, we get to know our anger because it keeps coming around. There’s no way to avoid it, though that doesn’t stop us from trying. Most of us recognize the different flavors over time; we even learn what flavor we prefer.

Many of us also learn that our anger won’t destroy us. The sharp edges of anger cause us pain, yes, but we know that the edges will become dull and the pain will recede. That never happens as fast as we wish; we grumble with annoyance and impatience as the days, weeks, months—maybe even years—pass. The anger burns, but its flames do not kill us.

We also learn that when we share our anger with others, whether we intend to or not, we often make ourselves vulnerable. Those who must work or live with us learn what our buttons are and how we react when they press them. Sometimes our distress makes them laugh at us. Indeed, there are people who will use the vulnerability within our anger against us. Many others, particularly those who care about us, learn more about who we are and appreciate us more, despite our anger.

Not only does our anger let other people know who we are, but it also tells us who we are, too. Sometimes we don’t like what we learn about ourselves when we’re angry. Other times, our anger reminds us and reaffirms what we value.

And sometimes you need to let people know that you’re angry so they learn what matters to you.

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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.

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Education Informal-curriculum Lessons Medicine Observations Reflection Systems

Thoughts on the Movie “Get Out”.

Have you seen the movie Get Out? If you haven’t, what follows might spoil part of the movie for you. You might want to watch it before reading this.

If you have seen Get Out, this post ponders the role of psychiatry in the movie. (Full disclosure: I enjoyed and recommend the movie.)

We learn early on in the movie that Rose’s mother is a psychiatrist. Chris, Rose’s boyfriend, asks something like, “She’s a psychologist?”

The response Chris receives is something like, “No, she’s a psychiatrist.”

While I can’t know for sure, I believe that the writer of the film, Jordan Peele[1. If you are not familiar with Jordan Peele, please go watch some clips of Key and Peele.], wanted to highlight the difference between the two. Psychiatrists are physicians. And some physicians, under the guise of expertise, have promoted racist ideas.

Dr. Samuel Cartwright was a physician who practiced in Alabama, Mississippi, and Louisiana in the years leading up to the American Civil War. He defended slavery and wrote pieces that argued that blacks were inferior to whites.

One of his articles, “Diseases and Peculiarities of the Negro Race“, describes “drapetomania, or the disease causing Negroes to run away”. Because he describes drapetomania “is as much a disease of the mind as any other species of mental alienation”, it is clear that this is a psychiatric condition, such as kleptomania (compulsive stealing), pyromania (compulsive fire-setting), and dipsomania (the old name for alcohol use disorders).

In this article Dr. Cartwright asserts that God has ordained blacks as “submissive knee-bender[s]” and are “intended to occupy… the position of submission”. To support that blacks were destined to be “submissive knee-benders”, he states that “in the anatomical conformation of his knees, we see [it] written in the physical structure of his knees, being more flexed or bent, than any other kind of a man.”

To prevent the development of drapetomania, he states:

if his master or overseer be kind and gracious in his hearing towards him, without condescension, and at the same time ministers to his physical wants, and protects him from abuses, the negro is spell-bound, and cannot run away.

In Get Out, Chris (plus Georgiana, Walter, and Andrew) becomes obviously “spell-bound” through the hypnotic powers of the porcelain cup and silver spoon. One could argue that Rose is demonstrating faith in this practice as she was initially “kind and gracious”, “without condescension”, “ministers to his physical wants”, and “protects him from abuses” (remember the police officer who pulled them over?).

Dr. Cartwright comments that, in the course of drapetomania, slaves become “sulky and dissatisfied” before they run away. He advises that “the cause of this sulkiness and dissatisfaction should be inquired into and removed, or they are apt to run away or fall into the negro consumption.” However, if slaves were “sulky and dissatisfied without cause,” he states that the treatment was “in favor of whipping them out of it, as a preventive measure against absconding, or other bad conduct. It was called whipping the devil out of them.”[2. Wikipedia also comments that another treatment for drapetomania included “removal of both big toes”, which makes running difficult.]

Chris becomes understandably “sulky and dissatisfied” with his time at the Armitage home and seeks to flee. Though he wasn’t whipped to treat his drapetomania, it’s not a hard stretch to argue that the plan to remove most of his brain (“coagula”) is essentially whipping the devil out of him so that only his body remains.

Dr. Cartwright apparently published these ideas in the New Orleans Medical and Surgical Journal (as well as De Bow’s Review, a magazine of “agricultural, commercial, and industrial progress and resource” in the American South). This publication came from his work as the chairman Louisiana State Medical Convention committee. One of their tasks was to “examine the diseases peculiar to the Black slaves of the antebellum South”.[3. From a Lancet article called “Drapetomania“.] This was a professional medical opinion!

To be clear, not all physicians agreed with Dr. Cartwright’s opinion. Dr. Hunt, a physician who practiced in Buffalo, New York—that is, North of the Mason-Dixon line—lampooned Dr. Cartwright’s concept of drapetomania. He rightly wondered why drapetomania seemed to only exist in the South. He made wry remarks that drapetomania seems to affect the neurons of slaves so that they only flee in a northerly direction. He also pointed out that drapetomania resembled the condition of schoolchildren who ran away from school to play.

In essence, Dr. Hunt shouted, “Context matters!”

Dr. Cartwright sincerely believed that drapetomania was an inherent quality of black people.[4. Dr. Cartwright also described “dysaethesia aethiopica“, or “hebetude or mind and obtuse sensibility of body” that only occurred in blacks in the South.] As he was a fish in the sea of Southern slaveowning culture, he either could or would not believe that social and political context affects the definitions of psychiatric conditions. (He also could not believe that his ideas were wrong.) Maybe Jordan Peele was thinking about Dr. Cartwright and drapetomania when he created the characters in Get Out. Maybe he wasn’t; maybe he was pointing out the consequences and longevity of racism.

Psychiatry has been and can easily become an agent of social control. The moment we begin to think that we’re too good or too smart or too sophisticated to become agents of social control, we and the people under our care are doomed.

It is paramount that we remember this always in the current political climate. May we have the wisdom and courage of Dr. Hunt.

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?