Category: Policy

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Blogosphere Medicine Observations Policy Systems

Why I Work at the Fringe.

This article is making the rounds among physicians on Twitter. Much of the information in the article, unfortunately, is accurate.

For some of the reasons stated there, I left the “traditional” health care system and pursued work at the “fringe”.

Part of this is due to my clinical interests: I like working at the intersections of different fields. For example, I like the intersection of psychiatry and hospital medicine, which is called psychosomatic medicine. Another example is my interest in public psychiatry, which focuses on the intersection of social factors and mental health (e.g., individuals with psychiatric and substance use conditions in the context of homelessness and poverty).[1. Really, though, all of medicine could be “psychosomatic medicine” or “public psychiatry”; the divisions between mind, body, and environment are arbitrary.]

Part of this, though, was my sense that the system would not let me be the kind of doctor I want to be.

For a brief period I worked in a clinic where I had slots for four new intakes a day (60 minutes each) and 15-minute follow-up appointments for the rest of the day. If my schedule was completely filled with follow-up appointments, I could have seen up to 34 patients a day. (I never got to this point because I quit well before my panel got full.)

In reality, the 15-minute appointments were 12-minute appointments. I needed about three minutes to type out some notes to myself for clinical documentation.[2. I don’t like typing my note while I am seeing a patient. I’m not fully attending to either one when I do that.]

Because I was building a new practice, people with a wide variety of conditions and concerns came to see me. I was advised to refer patients out of the medical center who were “too sick”. This included individuals who were frequently in and out of psychiatric hospitals, had significant psychiatric symptoms, or otherwise had other stressors in their lives that made them “difficult“.

In other words, they told me to refer out the people who needed specialist care the most.

The reality, too, was that no psychiatrist could provide quality care to these individuals in 12 minutes. Imagine someone with depression so severe that he lacks the energy or interest to share his current distress with you. Or someone who is psychotic and insists that her ex-husband is tracking her through all the electronics in her home. Or someone who is so anxious about leaving his house that his attendance to the clinic is worthy of celebration.

Obtaining an accurate history guides diagnosis, which then guides treatment. An insufficient history can thus lead to haphazard interventions. You can see how the 15-minute appointment model results in heavy reliance upon (potentially unnecessary) medications. If someone says he feels depressed, it’s difficult to validate his emotional experience, provide education about his condition and non-pharmacological ways to manage it (e.g., behavioral activation, sleep hygiene, etc.), and have a discussion about medications, which should always include risks, benefits, and alternatives, in 12 minutes.

It is much easier to write a script and ask someone to return in a month. (This inspired my post about the Automated Psychiatrist Machine.)

Furthermore, this clinic was in a medical center with a group of primary care physicians. Primary care doctors referred their patients with diagnoses of schizophrenia and bipolar disorder to the psychiatry clinic (as they should). These individuals, however, were “too sick”. Never mind that, unlike the primary care physicians, we psychiatrists had the training to diagnose, treat, and manage these individuals with significant psychiatric conditions.

Thus, these patients often returned to their poor primary care physicians, who tried to care for them the best they could… which often entailed medication regimens that were unnecessary. (Primary care physicians deserve no blame for this: How are they supposed to know?)

This clinic also “rewarded” psychiatrists for “productivity”. The more patients a psychiatrist saw, the more money the psychiatrist would earn. This led to “cherry-picking” patients. Psychiatrists would keep patients who either had minor conditions or symptoms that had resolved, because those are the patients you can adequately see in 12 minutes. As a consequence, patients with more debilitating symptoms could not access the clinic. The psychiatrists had no incentives in either time or money to send these “cherry-picked” patients back to their primary care doctors.

My frustration and disillusionment compelled me to leave the job. I returned to positions at the “fringe” to work with patients who often are also not part of the system or patients that the system had failed. Consider the man who has been homeless for the past ten years and is too paranoid to access any health care service. Or the woman who was beaten and molested as a child, sent to foster care and group homes, never completed high school, “aged out” of youth care, and now has no resources or support.

I couldn’t wait for the system to change, so I sought out settings where both my skills would be useful and I could be the kind of doctor I want to be. There may not be many physician jobs at the “fringe” and certainly not all physicians want to work there. When we physicians vote with our feet, though, we show what we value, the kind of care patients deserve, and how the system must change.

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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.”