Category: Policy

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COVID-19 Nonfiction Policy Public health psychiatry Systems

Pandemic of Demoralization.

I haven’t posted much recently because I don’t want to be a bummer. There’s enough of that in the world right now: disasters on a global scale and quiet tragedies just down the block.

I worry about the health care workforce. While it is indeed a privilege to go to school to learn about illness and health and then apply those skills to people who somehow trust us, this pandemic has squeezed and stretched us in ways none of us could anticipate. Not only do we see people who get sick with Covid-19, but we also see all the people who get sick from everything else because of the system pressures and failures due to Covid-19.

I see the fatigue on my colleagues’ faces; I see their struggles in trying to provide the best care they can when they themselves are not thinking or feeling their best—now going on for over a year.

We all remain focused on the Covid pandemic, though the demoralization[1. “Demoralization is a feeling state of dejection, hopelessness, and a sense of personal “incompetence” that may be tied to a loss of or threat to one’s own goals or values.”] pandemic has already descended upon us. While the pandemic has fostered more conversations about mental distress and illness, no robust system has emerged to take care of those who take care of others.[2. It is not only health care workers who would benefit from care from people and systems.] (How could we expect a robust system to emerge when the system—if there was one—was fragile prior to this pandemic?) This distress manifests in dreams and dissociation, prickliness and physical pain, withdrawal and wretchedness.

I never formulated my specific work as “public health psychiatry”, though, in the months before the pandemic, this idea crystalized in my mind. Most of my career has focused on the “deep end” of the system: homelessness, crisis, jails, and poverty. While people can and do get better, the challenges are great when one is reacting to, rather than navigating through, these barriers and systems.

So much of what I do is tertiary prevention (“managing disease post diagnosis to slow or stop disease progression“). Fewer people would need “deep end” services if there were more agile and reliable primary and secondary prevention systems. How much healthier would people be if they were never sexually assaulted as children? if parents were able to feed themselves and their children with confidence? if everyone had a stable and safe place to live?

For our health care workforce now, it is too late to prevent demoralization and exhaustion. It seems that the best that we can do is prevent more harm from happening. Tertiary prevention is still prevention, though this is hard to reconcile with the realities of our daily work: Will tertiary prevention buoy us enough so that we can give good enough care to our patients?

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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.

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Homelessness Medicine Nonfiction Policy Seattle Systems

More Reflections about COVID-19 from Seattle.

This is another unpolished post. Several physicians and nurses in other states have reached out to ask for suggestions and perspectives related to behavioral health and homelessness during this COVID-19 epidemic in Seattle. Here are some reflections:

Coordination with partners is not only essential for services, but also to maintain morale. No single agency is able to address this alone. Government partners need feedback and information about what the community needs (and, I’m sorry to say, sometimes the community ends up providing government officials with updates that government should be telling us). The actions and energy of partners can buoy others when it seems things are stuck.

There aren’t enough supplies. Clinics, hospitals, and agencies can’t get face masks, hand sanitizer, and other sanitation supplies. Vendors are all sold out. Local governments are appealing to the federal government to provide supplies; I understand that the US military protects a national stockpile of such items? Which is something I had never considered in the past. And, perhaps most importantly, there aren’t enough COVID-19 tests! It seems that most of our local publicly funded primary care clinics have, at most, 30 test kits on site with no replenishment coming. Some private labs are only now agreeing to provide COVID-19 testing.

Many employees don’t have enough paid time off accrued to take time off of work for self-quarantine. Thankfully, our state and federal governments have passed or will pass legislation to address this and ensure that people can still get paid despite having to take time off of work. HR departments everywhere would do well to look out for their employees, particularly those who provide direct service to people who are higher risk of experiencing illness due to COVID-19.

People may (or may not) bristle at the infringement of civil liberties. The Washington State Governor has banned gatherings of more than 250 people. The CDC has provided “mitigation strategies” specific to Seattle-King County for the next 30 days, some of which are about workplace behaviors and COVID-19, which includes checking temperatures for fever and screening for illness when employees show up to work. The CDC has also recommended prohibiting visitors to certain sites. These are extraordinary times, hence these extraordinary measures… and some people may bristle at having to follow these rules. So far, people have been voluntarily complying with these changes.

The balance of individual patient health information and public health wobbles. For the past two weeks, a local clinic and our shelter have gone back and forth (in a collegial way) about protecting an individual’s privacy versus protecting the health of other people staying in the shelter. In short, the clinic argued that if Mr. Doe, a person who stays in the shelter, gets tested for COVID-19, the shelter isn’t entitled to know (a) that the test occurred and (b) the test results. We have countered that the shelter should know about Mr. Doe’s testing and the results during this extraordinary time because we want to do everything we can to prevent or minimize a localized outbreak within our shelter. Thankfully, the State Attorney General issued guidance that sided with our view (to be clear, the clinic was sympathetic to our view and did not balk with the change in practice… and I completely understood where the clinic was coming from). However, this is something that the clinic and our shelter had to pursue on our own; this was not proactive guidance we received from our government officials.

Government bureaucracy is in full effect. In this instance, I’m referring to practice of government officials who are unwilling to send out official communication until numerous gatekeepers have vetted it. Thus, guidance is slow to come out, so everything slows down. I understand the reason for vetting—confusion isn’t helpful, either—but we also feel frustrated when we feel like we’re losing a race against an invisible enemy.

People staying in shelters are resilient. Many staff feel anxious about how COVID-19 will impact the people who stay in shelters and receive clinical services from us. I find that I have to remind myself that many of the people who stay in shelters have experienced traumas and horrors that we will never know or understand. Many of them have already experienced illnesses and pain that we cannot fathom. I do not mean to minimize the very real possibility that some of them, should they contract COVID-19, will develop severe illness and die. I don’t want that to happen, which is why we are in constant communication with our partners to coordinate services and care. However, many of them will either not get sick, or they will recover despite our anxiety and efforts. It is a privilege that these individuals even let us into their lives.

Screening guidelines for COVID-19 are mushy. Some of our local infectious disease experts have taken to crafting their own screening guidelines because they are dissatisfied with the vague guidelines from the CDC. (This ties back to the lack of available tests—if we had more COVID-19 test kits, then we wouldn’t be wringing our collective hands about screening guidelines, particularly for vulnerable populations like people staying in shelters, which, no kidding, includes a significant proportion of people who are over the age of 60.)

The workforce shortage seems like it will only get worse. Social service and health care agencies often struggle with having a sufficient number of staff to address the clinical need. As people call out due to illness, whether COVID-19 or otherwise, this will turn into a vicious cycle: Fewer staff for a constant or growing need means that those staff will get tired and sick, which increases the likelihood that they will call out, and if the return to work rate doesn’t match the “attrition” rate, then soon there will be only minimum staffing at best. We also cannot expect individual people to successfully address systemic problems. It is not uncommon for people who go into social and health services to overwork (whether in quantity, quality, or both); this is unsustainable during usual times, let alone during an epidemic.

Social distancing seems like it will have the highest yield. The Institute for Disease Modeling published a paper specific to King and Snohomish Counties (the “epicenter” of the outbreak in the US) about the importance of social distancing. It is both compelling and disturbing. I don’t know how to successfully balance this with the clinical services that the medical team provides to the agency. Telehealth options are limited because of the population we serve (i.e., they generally don’t have telephones), though we plan to implement some creative ideas to at least try to keep people out of emergency departments.

It’s a weird time. We continue to do the best that we can, while recognizing that what comes next may knock us off our feet.

Categories
Education Lessons Nonfiction Policy Reflection Systems

What I Learned in Government.

It’s been nearly four months since I posted something here. Don’t be fooled: The lack of words here did not mean an absence of word salads tossing about in my head.

I recently resigned from my job. (All The Things related to that contributed to my silence here.) My job had two parts: One involved administrative work as the behavioral health medical director for local government; the other involved direct clinical service in a jail. I was in that job for over five years. It took me about two and a half years to figure out what an administrative medical director does. (As the process of becoming a doctor involves frequently feeling incompetent, this discomfort wasn’t new to me.) Now that I’m on the other side of this job, here’s what I’ve learned:

I believe government can do good things. You know that stereotype that government employees are lazy? I did not find that to be true. Every organization has a proportion of staff who do not seem motivated or interested. The proportion, in my experience, does not seem higher in government. If anything, many of my colleagues came to government with eager hopes of improving the community. They came in early, stayed late, and worked on weekends. They convened groups with opposing viewpoints, advocated for different populations in the region, and expressed dissent to people in power. They sought out and willingly worked on complicated problems. They demonstrated the humility that comes with the realization that tax payers are funding their salaries.

I do not enjoy the game of politics. Some people love it! They enjoy the contests of status, flaunting their connections, and attacking perceived enemies in public forums with the brightest of smiles. Sometimes people asked me to speak, not because they cared about the content of my words, but because of my credential as a physician. (“Let’s trot out The Doctor.”) I grumbled about “perception management”; often it seemed that the surface sheen mattered more than the substance underneath. (On the other hand, it is likely that my glittery MD credential is what allowed me to say to superiors that poop will never develop a patina. It is unfair that systems often value specific people more simply because of the letters after their names.)

Government work has made me both more and less patient. It takes time to elicit ideas and information from “stakeholders”, community members, and others. People want to and should be involved if a policy or program will impact their lives. They share perspectives that government never thought to consider. I respect that process. I am less patient with the nonsense people and systems can generate to subvert fair processes. Some people are more prone than others to misuse power. That’s hard to watch in a system like government, which has access to and authority over so much money… and, in our current system, whoever has more money almost always has more power.

I learned a lot about laws and regulations. I came to appreciate the value of regulations, though they tend to address the lowest common denominator. Government spends most of its time aiming low to define the floor instead of inspiring people to elevate the ceiling. (I wrote more about this here.)

Government administrators forget what happens in direct service. Though many people in government once provided “front line” services—as attorneys, social workers, counselors, activists, whatever—many of them seem to forget the challenges of systems that are intended to help people. This includes the thousand little cuts of too much paperwork and the major crises of people dying due to missing or underfunded services. My opinion that all medical directors should routinely provide direct clinical service has only gotten stronger with this experience. Someone has to inform the others at The Table what’s going on outside.

Systems are made of people. Contemporary discourse often focuses on systems, not people… but people make up systems (i.e., individuals create, operate, and maintain systems). As such, single individuals can still have significant impacts on systems. This includes grinding things to a halt… or breathing life into new programs. (This is where political gamesmanship can be useful.) The hierarchical organizational chart can lead people who are “lower” to think that their efforts don’t matter, but that’s simply untrue. Systems can change because people can change… whether that’s because people actually change their ideas and behavior or people in certain positions leave.

I am deeply grateful for the opportunity to work in government. I never thought I would work as a civil servant (and, in fact, there was a time when I said I’d never work for government… which is why I’ve stopped making five-year plans). If for nothing else, now that I’ve been on the inside, I can use that experience and knowledge on the outside.

The outside suits me better. So it’s time to go back.

Categories
Policy Reflection Systems

Belonging in Psychiatry.

I recently finished reading The Art of Community: Seven Principles for Belonging by Charles Vogl. He starts the book with this definition of “community”:

a group of individuals who share a mutual concern for one another’s welfare.

He continues:

[A community] is distinct from a group whose members may share ideas, interests, proximity, or any number of things but lack concern for one another.

He argues that communities (as he defines it) have “shared values”, “membership identity”, “moral proscriptions”, and “insider understanding”.

The American Psychiatric Association (APA) held its annual meeting this past week in San Francisco. I did not attend.

I have never been a member of the APA. There was a time when I took some oppositional pride in this, though I was aware of how this attitude is problematic: I cannot help change an organization if I do not join it.

Why do I resist the APA, even though it is the organization that represents the work I do?

This excellent post over at Slate Star Codex captures many of my reasons: All of the pharmaceuticals! The overt and covert intersections with politics (which can lead to overmedicalization of life and underrecognition of psychiatry as an agent of social control)! And while I know that there are members of APA who care about people, families, and communities that experience severe psychiatric symptoms (e.g., schizophrenia, bipolar I disorder, co-occurring mental health and substance use disorders), I’ve never gotten the impression that these are priority populations for the APA.

If we use Vogl’s definition, the APA, to me, doesn’t feel like “a group of individuals who share a mutual concern for one another’s welfare”.

Maybe professional organizations aren’t intended to be spaces where people have mutual concern for the welfare of others.

In the past I wondered if my lack of affinity for APA had to do with how different my clinical practice is compared to other psychiatrists. There are other psychiatrists who work with people living on the streets and do housecalls for people who live at or near the poverty line… but we are few and far between. I live in the largest county in Washington State. There are hundreds of psychiatarists here. Yet I know of only two other psychiatrists who share my work experiences!

Consider emergency physicians. They all work in generally the same setting and thus have similar clinical practices. I don’t know the membership of their professional organization (American College of Emergency Physicians), though it at least seems that their specialty organization is more cohesive and united. Because their clinical practice is more uniform, perhaps it is easier to have mutual concern for the welfare of their fellow physicians.

Meanwhile, how much does my work have in common with the private practice psychiatrist who provides psychoanalysis? I’m just trying to get the guy who lives outside due to relentless paranoia to look at me long enough so I can say hello in a manner that won’t scare him off.

A few years ago a local psychiatric association contacted me. They anticipated an upcoming vacancy in a committee involved in government relations.

During the phone call, I learned that most of the members were psychiatrists in private practice. The leadership expressed a desire for the association to get more involved in government affairs (e.g., local and state legislation). Because of my role in local government, they highlighted the value I could contribute to the association.

“You’ll have a lot of influence,” they said several times.

They also commented that they were trying to increase the diversity in their organization. In addition to the “influence” I could bring, I could also bring my non-white, non-male self.

By the end of the phone call, I said that I wanted time to think about it. What I actually thought about was the responsibilities I had to myself versus those I would have to the organization. I cannot help change an organization if I do not join it. Could I bring issues related to underserved communities to the association? Would the membership find these issues compelling? Would they have interest in legislation that did not focus on their own patient populations?

A few weeks later, I told them that I wouldn’t join. This decision stemmed chiefly from the substance of the work. However, it was also a reaction to their recruitment methods: They thought I would respond favorably to an appeal to my vanity. “You’ll have so much influence!!!” Perhaps the corollary to that was that my influence would help get stuff done, but the emphasis was on the vast amounts of influence I could wield over the group. That didn’t interest me.

And while I did appreciate the blunt commentary about how my participation would help increase the diversity of the association, it made me tired just thinking about it. Increasing diversity doesn’t just mean increasing the amount of color in a photograph. There’s a lot of work in introducing and maintaining various perspectives in a group. I didn’t want to be the only person responsible for that simply because of my non-white, non-male status.

The association certainly had concern for its own welfare. I wasn’t convinced that the association members had concern for mine.

To be clear, this doesn’t mean I’m great.

At least once a week I wonder if I would be more effective in my medical director role if I were involved in more associations and groups. What if I could bring the “forces” of the local medical society and psychiatric association to my job? What if I could use my status as a medical director in government to influence the priorities of these organizations? Would my “success” in each sphere be greater?

What responsibilities am I shirking? I believe one function of government is to convene people so we can figure out how to collaborate with each other. How many opportunities am I missing to improve the community because I am not participating in these other organizations? If I really care that much about underserved populations, don’t I have some responsibility to persuade these organizations to support initiatives that will serve the the underserved? Isn’t there more strength in numbers?

What would it be like if I shared and coordinated ideas, plans, and concerns with these big organizations with large audiences instead of here on my blog?

This has been true from the very beginning: I am a reluctant psychiatrist. I was never supposed to become a psychiatrist.

But, for reasons known and unknown, people experiencing psychotic symptoms feel comfortable talking to me.

So, here I am, working as a psychiatrist.

And, perhaps because of my affinity for complex problems, this is also why I am more comfortable working at the boundaries of fields. Yes, it is possible that the APA will create and disseminate the cure schizophrenia.

I doubt it.

I don’t think a pharmaceutical product will cure schizophrenia. But, at the intersection of nutrition science and psychiatry we can maximize the likelihood that pregnant women will have access to foods that will decrease the risk of their babies developing schizophrenia. At the intersection of legal systems and psychiatry we can reduce (if not eradicate) the use of solitary confinement so that jails and prisons do not worsen psychiatric symptoms. At the intersection of education and psychiatry we can teach kids and their parents skills to better cope with the adversity that life throws at all of us.

I will continue to struggle with joining APA and other organizations. But I already know that I’m not alone. Those of us—and not just psychiatrists—who care about the welfare of people with severe psychiatric symptoms are already part of a community. Sometimes we’re just harder to find.