Category: Policy

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Consult-Liaison Medicine Observations Policy Systems

Ever Seen a Hospital Orientation?

Perhaps more important than the actual “rules” of hospitals is how these “rules” are communicated to patients.

Medical students spend two years training in a hospital before they work as physicians. It often took me over a week on a specific service (e.g., surgery) to understand its routines and rhythms. While it is true that patients and hospital staff have different roles in the hospital, how can we expect patients to understand their roles upon admission?

Those of you who work in hospitals might be thinking, “But patients don’t have roles in the hospital. They’re there to receive care.” Of course patients have roles in the hospital. When patients deviate from the roles you think they should play, that’s when you start calling them “difficult” and then consult psychiatry.

In general, hospitals have not honed their skills in orienting patients to their roles in the hospital. Rarely does anyone tell you what to do or what to expect when you go to the hospital. This orientation may happen on an individual level (thank you, nurses!), but it is an uncommon institutional practice.

Consider all the places you visit that are not “yours”, though you might be labelled the “customer”. How about fast food joints? They often have signs that tell you where you order your food and where to pick it up. The cash registers tell you where you pay. Shallow corrals tell you where to line up. Those are small details, but they help define your role and shape your behaviors while you are in the fast food restaurant.

Hospitals would do well to adopt the practices of airlines. Have you been on an airplane? Remember how you paid attention to the safety announcements before your first flight? The flight attendants tell you how your seatbelt works, point out the exits to you, tell you about the flotation device that is disguised as a seat cushion, and how to work the oxygen masks that will appear if the cabin pressure drops. It only takes a few minutes. And, in case you want to review the information on your own, they include all of that information “on the card in the seat back pocket in front of you“. Have you ever looked at that card? There are few words on it: It aims to be universally understood.

Why not include a small booklet—comic book?—in each hospital room that provides similar orientation?

Consider hotels. Not only do hotels have written material in each room about hotel operations, but some of them also have a television channel dedicated to hotel features and operations!

Most hospital rooms have a television bolted to the ceiling or to the wall. Why not develop a “hospital channel” that offers similar information about hospital operations and features?

A skim through Google shows me that some children’s hospitals (in Cincinnati and Chapel Hill) have created YouTube videos that offer hospital orientation to kids. Why do we not do the same for adults?

When I have worked in hospitals, I often felt like there wasn’t enough time for me to do everything I needed and wanted to do. When I sat in my mother’s hospital room, I was surprised with how much waiting we did. That time could be used to teach patients and their family members what to expect during the hospitalization, like when the doctors typically round (and what “rounding” even means) or what to do when the IV starts to beep.

If you work as a hospital CEO or at a similar paygrade, I encourage you to work on easy-to-understand materials that orient patients to their roles in the hospital. Realize that patients want their hospital stays to go smoothly. They want to know what to expect. The vast majority of patients don’t want to “bother” hospital staff. They want to help hospital staff so that the medical staff can help them. Patients don’t want to stay at the hospital longer than they have to.

Understand that hospital orientation is like building rapport on an organizational level. Data shows that effective communication between physicians and patients leads to better patient health outcomes. If the outcomes are better on an individual level, why couldn’t outcomes improve on an institutional level?

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Education Homelessness Policy Reflection

Commercial Sexual Exploitation.

I recently attended a presentation given by one of the founders of The Organization for Prostitution Survivors (OPS).

If you or your organization want to hear a compelling, educational, and thoughtful talk about commercial sexual exploitation, I encourage you to contact OPS.

The talk did not necessarily alter the way I go about my work as a psychiatrist, but it did challenge my assumptions about prostitution, highlight the different perspectives men and women have about sex (to be clear, the talk was not at all “anti-male”), and encourage me to reconsider the influences of our culture on commercial sexual exploitation.

I’ve included my notes and reactions from the presentation below. Any errors and lack of clarity are entirely mine.

The speaker (a man) began with a discussion about the social construction of gender. What does it mean to “act like a man”? The stereotype is that a “man” excels at sports, fights well, doesn’t show emotions (particularly sadness, fear, etc.), is dominant, and is skilled at and knows a lot about (heterosexual) sex.

Boys learn these stereotypes throughout their youth. Boys are eventually introduced to pornography, which may actually serve a means of male bonding (passing around a copy of Playboy, sharing links to online pornography, etc.). Pornography doesn’t teach boys how about sexual relationships, but instead offers flat, two-dimensional representations of women solely in the context of sex. Masturbation leads to orgasm, which is a potent reward for viewing women as sexual objects (instead of actual people).

The speaker then asked the audience for adjectives attributed to “good girls” and “bad girls”. The assumptions about “bad girls” are often the same for prostituted women[1. The speaker used the phrase “prostituted woman” instead of “prostitute” for the same reason that I use “man with a diagnosis of schizophrenia” instead of “schizophrenic”. Let’s please remember that we are talking about actual people here.] (they have multiple sex partners; they drink alcohol and use drugs; etc.). The words we use to denigrate women are synonyms for prostituted women: whore, slut, etc.

As a consequence, prostituted women become a legitimate target group for male violence. We somehow come to believe that it is okay for men to hurt prostituted women. They are, after all, “bad girls”.

The speaker discussed Gary Ridgway (the “Green River Killer”), who sought out prostituted women and murdered them. Nearly half of the women he killed were under the age of 18. The speaker asked why the media consistently describes these women as “prostitutes” and omits that nearly half of them were, in fact, “children”? What if we described Gary Ridgway as the “most prolific killer of children” in American history?

The speaker then described how a former pimp would find and select women (girls). His strategy was essentially this: If he spoke to a woman and she responded with any direct eye contact (even if she was flattered), he would walk away and end the “grooming” process right there.

Why? Because he knew that those women who made no eye contact with him already had life experiences that would make the pimp’s job easier. “Someone else has already beaten her down so I don’t need to do as much to make her work.”

The speaker then noted that researchers often wonder about the mental health of prostituted women… but why hasn’t anyone examined the mental health of buyers and pimps (mostly men)? Prostituted women often develop PTSD, which is unsurprising given the chronic trauma they endure while working. What is wrong with us as a society that we haven’t shown the same interest in what is “wrong” with the johns?

A discussion followed about the words we use to describe men viewing women. In the US, we often say that men “ogle” or “leer at” women. Those words have a “hubba hubba hubba!” quality to them; men who want an interactive, romantic relationship don’t “ogle” or “leer at” women. When was the last time you heard of a man “beholding” a woman?

One of the most striking points the speaker made was when he asked, “To the men in the audience: What do you do to protect yourself from rape?”

Silence ensued. Some men in the audience were perplexed.

“To the women in the audience: What do you do to protect yourself from rape?”

Many women answered immediately: “Travel in pairs.” “Keep my drinks with me at all times when I’m out.” etc.

Both men and women in the audience were stunned at the disparity of responses.

The speaker then discussed the issue of consent: Consent for sex should be an “enthusiastic yes!”, not something that requires negotiation. In prostitution, the exchange of money for sex is coercion. Economic coercion is never true consent.

The speaker also commented that buyers aren’t paying to learn the reality of the prostituted woman. If the girl is 16 years old and the buying man asks her age, of course she is going to say that she is 18. If he asks her if she has a pimp, of course she will deny it.

The speaker then challenged the audience to speak up even when someone tells a sexist joke against women. Doing so helps to construct a world of equality where women aren’t reduced to sexual objects. He commented that a sexist joke is on a continuum that also includes a man forcing his wife to have with him (“why did I get married if I couldn’t have sex with her whenever I wanted?”), paying a prostituted woman for sex, rape, and murdering women.

The speaker shared that prostitution “is like domestic violence on crack”. The cycle of abuse applies to both. He reported that prostituted women leave and return to their pimps between seven and ten times before leaving for good. It is often difficult for the women to leave because they often identify with their pimps due to something like Stockholm syndrome, though “trauma-bonding” is probably more precise. Prostituted women also frequently develop drug and alcohol problems as a means of coping with the ongoing trauma associated with the work. (Imagine getting into the cars of buyers multiple times a night without knowing if you will get hurt; imagine a pimp beating you because you did not bring back sufficient earnings; etc.)

The speaker also discussed the “bad date list”, which has historically been a paper list that prostituted women have passed around with names and identifying information of buyers who don’t pay, hurt the women, etc. He said that they hope to develop a “bad date” app because of the ubiquity of smart phones.

The speaker closed by discussing different models of managing prostitution in societies. He said that he is strongly opposed to legalized prostitution. He cited some data where states and countries with legalized prostitution often results in more sex trafficking and prostitution. He gave the example of Germany: The demand for prostitution has gone up since it has become legal, so Eastern European women are often lured and trafficked into Germany to work as prostitutes.

He expressed hope in the “Swedish model“: Sweden has taken the approach that women working in prostitution are victims and, thus, the selling of sex is not considered a crime. However, buyers, pimps, and traffickers are prosecuted to the fullest extent of the law. Some data suggests that, as a consequence, there is less visible prostitution and fewer women working in prostitution.

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Education Observations Policy Reading

DSM-5: Post-Traumatic Stress Disorder (PTSD).

This is another post from my DSM-5 e-mail list. If you find the information below useful or interesting, you are welcome to join.

(747 words = 5 min read)

The essential feature of PTSD is the development of reactive symptoms following exposure to a traumatic event. The diagnosis of PTSD has notable changes in DSM-5.

One difference is that, according to DSM-5, a person no longer needs to experience emotional reactions (“intense fear, helplessness, or horror” described in DSM-IV) to the trauma.

The authors provide a long list to describe criterion A (“exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways”). Note that sexual violence is now included in the definition.

Criterion A also allows for the diagnosis of PTSD for individuals who have had only indirect exposure to the trauma, though the trauma must have occurred to “close relatives or friends”. There is also a clause for repeated and extreme exposures, such as what paramedics and other first responders witness. The events of September 11, 2001, have influenced this diagnosis.

Criterion B, previously the “re-experiencing” sphere, is now the “intrusion” sphere. These symptoms include memories, nightmares, dissociation, and distressing reactions to internal and external cues related to the trauma.

Criterion C remains the “avoidance” sphere (avoidance of both internal and external reminders), though patients only need to meet one of two criteria in DSM-5 (versus three of seven in DSM-IV).

Criterion D encompasses “negative alterations in cognitions and mood”, which includes memory problems, negative thoughts (think Beck’s cognitive theory of depression), and resulting distressing emotions. This criterion helps capture the “comorbidity” of depression seen in PTSD.

Criterion E is the “hyperarousal” sphere that describes the irritability, “jumpiness”, and paranoia often seen in PTSD.

The authors note that these symptoms must persist for at least one month and cause “clinically significant distress or impairment”. As usual, they ask that the reader ensure that these symptoms are not due to a medical problems or a substance use disorder. There are only two specifiers:

  • with dissociative symptoms (depersonalization or derealization)
  • with delayed expression (full criteria are not met until at least six months after the event… the authors state that there is “abundant evidence” to support the delay in symptom appearance, but do not offer any explanations as to why)

The authors also include PTSD criteria for children ages six and under (which I will not review here, since I only work with adults… child psychiatrists, I direct you to page 272).

The authors note “auditory pseudo-hallucinations, such as having the sensory experience of hearing one’s thoughts spoken in one or more voices”, as well as paranoid ideation, can be present in PTSD. I find this useful because, previously, I’d give a primary diagnosis of PTSD and a secondary diagnosis of “psychosis NOS”, though it was clear that these were not “organic” psychotic symptoms.

The authors also note that prolonged exposure to trauma can result in emotion dysregulation, problems with stable interpersonal relationships, and dissociative symptoms… which sounds a lot like borderline personality disorder.

DSM-5 states that the projected lifetime risk for PTSD is only about 9%. This speaks to the resilience people possess, as much more than 9% of the population experiences trauma described in criterion A. Complete recovery is within three months for about half of adults. This again is a testament to the resilience people have.

PTSD is also diagnosed much more in the US than in other Western countries. (Paul McHugh has written a lot about the amplification of PTSD in the US.) Women are more likely than men to receive a diagnosis of PTSD. Those at highest risk of developing PTSD include survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide.

The authors divide risk factors for PTSD into three groups:

  1. pretraumatic factors (temperament; childhood adversity; racial minority; etc.)
  2. peritraumatic factors (severity/dose of trauma; interpersonal violence; etc.)
  3. posttraumatic factors (“negative appraisals”; exposure to upsetting reminders; etc.)

The differential diagnosis for PTSD is one of the largest in psychiatry; it includes other stress disorders, mood disorders, personality disorders, psychotic disorders, and neurocognitive disorders. PTSD also has many “comorbid” conditions as already noted above; DSM-5 states that 80% of people diagnosed with PTSD are likely to have symptoms that meet criteria for another mood, anxiety, or substance use disorder.

Anecdotally speaking, people wrestling with homelessness and poverty often have a significant history of trauma. We might assume that the homeless caused their own problems. When you start asking clarifying questions, however, you often learn that they had horrifying childhoods. Just some food for thought.

Next time: Probably bipolar disorder.

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Education Lessons Medicine Policy

Involuntary Commitment (VI).

Recall in the second scenario the man who was throwing his furniture out of his apartment due to concerns that someone or something was trying to take over his room. How would you apply involuntary commitment criteria here?

1. Does this person want to harm himself or someone else?

There isn’t compelling evidence that he wanted to harm himself—if anything, he suggested that his behaviors were attempts at self-preservation.

Though he never said that he wanted to harm someone else, his behavior was inadvertently putting other people in danger: He had already thrown stuff out the window, where it could have injured people on the sidewalk. He also threw a guitar in your direction, though, thankfully, it didn’t hit you.

2. How imminent is this risk of harm to self or others?

Imminent. He does not appear to be responding to direction to stop throwing things and perhaps it is only luck that the items he has thrown has not hurt anyone.

3. Are these behaviors due to a psychiatric condition?

Probably.

Given what we know about his history and the timeline of events, it seems likely that these behaviors are due to a psychiatric condition. However, these behaviors could feasibly be due to drug use or medical problems.

Related: Will hospitalization help treat the underlying psychiatric condition?

Probably. Hospitalization has historically helped this man recover from his acute symptoms.

What actually happened?

After the guitar crashed into the wall, other people—neighbors, staff—arrived. The man had retreated back into his room and continued to shout: “People don’t UNDERSTAND none of this is MINE how did this even HAPPEN why did I think it was OKAY I won’t let it happen again I won’t let it happen again—”

After tucking myself around the corner, I shooed away the neighbors; they needed to get out of there for their own safety. A social worker used her hands to mime making a phone call, her eyebrows raised as if asking a question. I nodded.

“Hey,” I said in a quiet voice[1. The next time you’re trying to lower the volume of someone else’s voice, try lowering the volume of your own voice. It’s hard to yell when the other person is barely audible.], “I’m sorry you’re feeling overwhelmed. Just so you know, though, we’re calling 911. I’m worried about you.”

He grabbed the clock off of the wall with one hand and a framed photo of his sister and him with the other and threw both out the window. Both shattered when they hit the sidewalk.

“I DON’T CARE you can do whatever the F@#$ you want I just NEED to get rid of all this SH!T—”

The rest of us waited.

Before the police and paramedics arrived, he had thrown a floor lamp, more silverware, and much of his clothing out the window. Papers were scattered on the floor. He smashed all the mirrors in his apartment. He tore the curtains from the walls. He threw several pieces of fruit, one remote control, and his pillows out into the hallway.

I braced myself as the police appeared in the hallway. Please cooperate… please cooperate… I hope the cops won’t be jerks…

The social worker had already briefed the police and paramedics about the situation.

“You Dr. Yang?” an officer asked. I nodded.

“And that’s the guy?”

“Yes.”

“We’ll take it from here. Can you write an affidavit?”[2. An affidavit is a written declaration that is used in court, in this case to hospitalize this man against his will. The police were asking me to write the affidavit because of my credential and because of my relationship with the patient. This affidavit included my opinion that he was a danger to others, given that he had thrown a guitar at me and had continuously thrown items out of his window.]

He was rummaging through his closet when the officers knocked on the door. He looked over his shoulder and paused as the officers greeted him. A few beats of silence followed.

“OH GOD WHY WON’T THEY LEAVE ME ALONE?” the man suddenly bawled. He fell to the ground and began to weep. After glancing at each other and then me, the officers and paramedics walked in.

He initially balked at their overtures about transport to the hospital, though he ultimately agreed. He choked on his sobs on the gurney as the paramedics wheeled him down the hallway.

He was in the hospital for over a month.

At our next appointment, he sat in the chair, his eyes glazed over, his body twenty pounds heavier.

“I’m sorry about what happened that day,” he said.

“That’s okay,” I murmured. “I’m glad you’re here.”

Categories
Education Homelessness Lessons Medicine NYC Policy

Involuntary Commitment (V).

Recall that the first scenario described a homeless woman who did not seem inclined to move to shelter despite the forecast of a heavy snowstorm. How would you apply involuntary commitment criteria?

1. Does this person want to harm himself or someone else?

There was no evidence at that time to suggest that she was considering suicide or homicide. One might wonder about grave disability, as her behavior in that context was not consistent with most other homeless people at that time. (Because of the pending snowstorm, most of the homeless encampments were empty that morning.)

2. How imminent is this risk of harm to self or others?

Imminent. The snowstorm had already started and six inches were forecasted to cover the ground in the next few hours. If the snowstorm occurred as predicted and she did not move, she would be at significant risk of developing hypothermia, frostbite, or complications from both.

3. Are these behaviors due to a psychiatric condition?

Maybe.

She had mentioned one thing (“The government secrets are safe with me”) that might suggest a delusion, though we don’t really know what she meant when she said that. Her behavior suggests paranoia, though it is also understandable if people don’t want to talk to strangers.

Just because someone is homeless does not automatically mean that mental illness is present, though individuals who are chronically homeless are more likely to have a mental illness. Given what we knew about her, it seemed more likely than not that she has a psychiatric condition.

Related: Will hospitalization help treat the underlying psychiatric condition?

Maybe.

If it isn’t clear if she has a psychiatric condition, then it isn’t clear if hospitalization would help.

So what actually happened?

The outreach workers working with me wanted to send her to the hospital for evaluation and treatment. I wasn’t confident that she would actually be hospitalized. If I was working in an psychiatric emergency room, I probably would have released her. Her presentation did not seem to meet a minimum threshold for dangerousness, though she did not appear well.

The snow continued to fall. No one said anything. I excused myself to step away and consider the options.

I was worried about her. She had reported that she had been homeless for decades in New York; this wasn’t the first major snowstorm to hit the area. However, she was now older and just because she survived past snowstorms did not mean that she would survive this one. Furthermore, other individuals with comparable experience with homelessness had abandoned their campsites that morning—why hadn’t she?

In New York State, two physicians are required to detain a person against her will. If I began the process in the street, the emergency room psychiatrist could either complete the process or reject my proposal and release the individual.

With reluctance, I ultimately began the process for involuntary commitment. I was not convinced that she needed hospitalization, though I knew that the process would take several hours. Hopefully, the snow storm would blow through in that time.

She wasn’t pleased when the ambulance arrived (“I’m fine… I’m fine…”), though she did not resist the paramedics. I sat in the back of the ambulance with her. She was shivering. Neither one of us said anything; what could we talk about?

“So… what do you think of this weather we’re having?”

Upon arrival at the emergency room, I gave a brief report and the commitment paperwork to the psychiatrist on duty. The psychiatrist commented that he had never seen her before, which did not surprise me: Sometimes the most vulnerable and ill individuals never interact with the health care system.

“From what you’re telling me, I don’t think we’re going to detain her,” the emergency room psychiatrist said.

“I understand.”

A guard and a nurse asked her to empty out her pockets and remove her parka. She did not balk. Though I knew she was thin, I was taken aback with just how slender her frame was.

The snowstorm blew through. Close to eight inches collected on the ground. The rare pedestrian dashed across the empty streets through the blurry grey air.

I got a phone call as the storm was ending.

“We’re not going to hospitalize her; there’s not enough.”

“That’s fine. Thanks for letting me know.”

The next time I saw her she was standing on a corner, her hands in the pockets of that same parka. When I greeted her, she turned around and walked away quickly. She spurned my greetings for nearly three months.

I understood and could not blame her.

Only after three months did she finally agree to talk with me. One brisk morning, while she was still tucked under the plastic bags filled with paper, she finally told me her story. She probably demonstrated significant psychiatric symptoms in the past (and was probably diagnosed with schizophrenia), though she experienced less symptoms now. She still didn’t want housing because she believed that she didn’t deserve housing.

I left New York and she remained. I still think about her occasionally and wonder if she is still alive.