Category: Reflection

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Education Medicine Nonfiction Reflection

A Week in School!

I spent the past week at a health care ethics seminar. Here are some reflections:

How lucky was I to spend a week in school? The last time I sat in a classroom for five consecutive days was about 15 years ago. Prior to starting my clinical rotations in medical school, I was a professional student: There were 18 years between kindergarten and my second year of medical school. I got really skilled at sitting in classrooms, listening to people talk at me, and organizing the information for either tests or real-world application.

I’ve recognized the privilege of attending school. I don’t think I appreciated the depth of this privilege until this past week.

Different perspectives makes for rich learning. Most of the students in this seminar came from three professions: Chaplains, nurses, and physicians. There were some social workers, as well as an attorney or two.

There were further divisions within those groups: Some people were professionals within the military; others came from Catholic hospitals; multiple medical specialties were present. Most of the people there were already participating in ethics committees.

The different perspectives that each profession, specialty, and individual brought were useful. Decisions by committee can be onerous (cf. the pain of some meetings), but discussing and learning within committees is often humbling and fascinating. My classmates brought up ideas and arguments that I would not have considered.

One wonders if these rich discussions occur because we know our time together as a group is limited. In standing meetings in our usual jobs, we sometimes get accustomed to who says what and why. We might also face formal or informal consequences for speaking up (or not speaking up). In a week-long seminar, what have you got to lose by sharing your thoughts?

On not speaking up. As both a student and physician, I continue to receive feedback that I should talk more. (Given how much I blather here, one might find this surprising.) When I was a student, sometimes teachers thought I didn’t care about the topic. (Usually untrue.) Sometimes they thought I was shy. (I’m not, though people who haven’t gotten to know me might think otherwise.)

These days, sometimes people wish I would speak up to demonstrate my expertise. Sometimes I get the impression that some people want to know what I’m thinking, but when I don’t speak, they believe I’m withholding information on purpose. (Rarely true.)

There was plenty of dialogue that occurred between teacher and student and between students during the lectures. I said little. The admonitions from my past (and present) echoed in my ears: “You’re not talking! You’re not contributing to the group! Why don’t you say something and help out?”

Honestly, I think I’m just a slow thinker. It’s not that I don’t have opinions; I just find myself thinking about multiple perspectives at the same time. This muddles my thoughts. Muddled thoughts often leads me to produce incoherent speech. While I’m slowly clarifying a single line of thought, others who are able to organize their thoughts faster have raised their hands and are ready to speak.

Health care ethics isn’t limited to death and dying. Most of the discussions we had during the seminar surrounded death and dying. For example: A child is in a coma in the intensive care unit. The medical team wants to proceed with further interventions and treatment that has a 50% chance of recovery. The parents of the child want to withdraw treatment, which means imminent death. Discuss.

I imagine that most ethics consultations in the hospital are related to death and dying. But what about all the other ethical quandaries that are not as “glamorous”, but occur more frequently?

Like informed consent for medications. How much informing is “enough”? How much detail of the risks, benefits, and alternatives should we offer? If someone doesn’t want the information, but wants the treatment, is that a valid consent?

When I was a resident, one of my attendings commented in half-jest, “A common problem with informed consent is that by the time someone is truly informed, they are not able to provide consent… and when someone consents, they are not truly informed. Consider someone who is experiencing CPR: The chest compressions, the mouth-to-mouth breathing, the ribs breaking. That person is completely informed about CPR now… but he can’t consent. But when we obtain consent about CPR, that person usually has no idea what happens during CPR.”

Involuntary treatment is a big deal in psychiatry (as it should be). Sometimes we don’t seem to devote sufficient attention to all of its ethical issues.

The value of teachers showing vulnerability. Some of the speakers at this seminar take care of patients. They offered real clinical examples of ethical quandaries (e.g., a patient who doesn’t want to know her diagnosis, even though the physician believes that the patient should know). Those discussions were the most compelling because these teachers had opinions about what to do, but were not sure and still are not sure if they did the “right” thing.

I admired the thoughtfulness and humility of these speakers. Ambiguity is present in all of medicine. Sometimes we—all of us, regardless of our role—want a clear, concrete answer, but it doesn’t exist. Sometimes people craft an answer to reduce the motion sickness they feel while floating on the sea of ambiguity. It takes courage to recognize that sometimes there is no anchor, that the clouds are blocking the stars, that we don’t know where we are or what to do next. We just do the best we can with the information we have at the moment.

The value of pithiness. Several of the instructors seemed to speak solely in aphorisms. It didn’t matter how muddled or disorganized our questions were; they reformulated our questions with wisdom and clarity and provided concise answers.

I wish I could do that all the time.

Each instructor highlighted the importance of clarifying the ethics consultation question. This idea was also drilled into our minds as psychiatry residents when we were learning how to do hospital consults. What is the question? It doesn’t matter how great the answer is if it doesn’t actually address the question. And sometimes we don’t know what we’re asking.

Pithiness comes from clear thinking. Clear thinking comes from understanding the issue at hand. We don’t understand the “issue at hand” unless we ask questions.

Of course, these instructors have been thinking about ethics for years. They have likely heard our questions or some variant of them before. The various moral frameworks (e.g., utilitarianism, deontology, virtue ethics, etc.) are novel to us, but not to them.

It also takes time to think clearly. The time pressures inherent in clinical medicine contribute to muddled thinking or, in the worst case scenario, not thinking at all. This is yet another reason why I was grateful to attend this seminar: There was time to think, reflect, and consider the “bigger” picture of the work we do.

As I’ve noted before, the more experience I get, the more I realize how much I don’t know. (It’s disturbing.) This is why I now value more how to think, rather than what to think. The content changes over time as psychiatry makes (slow) advances. Knowing how to apply this information in the service of caring for patients is paramount.

For those of you interested in health care ethics, the primary paradigm this seminar used is called the “four boxes“. Look over my Twitter timeline for more comments about the seminar (though I stopped sharing much after day three, only because my mind felt full).

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Education Lessons Medicine Nonfiction Reflection Seattle

It’s Good to be Busy.

It was a busy day:

There was the guy who spoke with enthusiasm about his doctrine of RUL (“Righteous Unconditional Love”); the man who stared through me after I asked him about whether he had eaten that morning; the fellow who made no efforts to hide his nose-picking while expressing his frustration with the court system; the young man who wouldn’t let me inspect the wound on his hand, though I soon recognized that he had crafted the wound out of a packet of juice crystals; the man who hadn’t taken a shower in several months, though the odor bothered me more than it bothered him; the guy who boasted about his abilities to run a mile in two minutes; the man who refused to acknowledge my existence; the fellow who advised me that he would prefer to take his medications in the morning because that’s what his nurse practitioner told him to do; the man who apologized for masturbating, but argued that he is young and “that’s what young people do”; the fellow who said that after he used “bad heroin”, he realized that his parents aren’t actually his parents; the guy who found lithium energizing and was in the process of tapering off of methadone; and the man who simply said, “I’m not sick,” when I asked him why he hadn’t been taking medication that the state psychiatric hospital had prescribed to him. Nurses paged to ask for orders for medications to reduce the discomfort of heroin withdrawal, medications that patients had asked for three days ago, medications that patients took before they entered jail. The phone rang as callers shared information about diagnosis, treatment, and next steps.

I tipped my head back in the chair, stretched my arms up, and sighed.

“You okay?”

It was my second year of residency and I was the only psychiatrist in the hospital that night. My duties included addressing any issues that occurred in the psychiatric unit and providing care for any patients that came to the emergency department with psychiatric concerns.

My classmates had warned me about a particular emergency medicine attending physician who was working that night:

  • “Last week he told me I was useless.”
  • “He rolls his eyes at me all the time.”
  • “He’s just angry. He won’t ever thank you for anything you do.”

“Hi, Dr. Angry,” I said around 7pm. “I’m the psychiatry resident on call tonight.”

After glancing at me, Dr. Angry grunted.

Well, I guess that’s how it’s going to go tonight.

Less than three hours later, after Dr. Angry referred four patients to me, he muttered in my direction, “I’ve got another one for you.”

Shortly after midnight, a patient’s husband was pulling her out of the ED while she was screaming at me.

“I’M GOING TO GET YOU FIRED FROM HERE! YOU’RE A TERRIBLE DOCTOR! I KNOW THE PRESIDENT OF THE HOSPITAL! YOU CAN’T DO THIS TO ME!”

I was shaking, but I wasn’t going to admit her to the hospital. Dr. Angry caught my eye and nodded once. I wasn’t the only person who knew I was shaking.

It was close to 3am and I had already seen seven patients.

Dr. Angry had a slight smile on his face as he approached me while I was slogging through my notes.

“Dr. Yang, there’s another one for you to see.”

please make it stop

“Thank you. Who is it?”

As I was beginning my note around 6am for the ninth patient I saw, Dr. Angry stopped by.

“Dr. Yang, you did all right. Thank you.”

“You’re welcome, Dr. Angry.”

I tipped my head back forward in the chair in the jail and dropped my arms.

“Yeah, I’m fine,” I replied to my colleague. “It’s busy, but it’s good to be busy. And when I think about my intern year, this isn’t bad at all.”

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Education Lessons Medicine Reflection

Talking About Suicide.

I was recently asked to speak at a community event about youth suicide. Several young people in the area had killed themselves in the past few months to years. This was an opportunity for the community to learn and talk about suicide and suicide prevention.

My role was to provide a professional perspective on and information about suicide in young people. There was also a panel of people between the ages of 16 and 19 who shared their perspectives about suicide. The youth panel was the most compelling aspect of the evening.

The audience was comprised entirely of adults. Most were probably parents; others were adults who often interact with young people, such as school administrators and police. The youth panel encouraged the audience to talk to the young people in their lives about death, dying, and suicide. The panel also spoke about the importance of showing that they, as adults, care about young people. They shared their experiences in how talking about suicide with their peers has given others hope and saved lives.

One girl shared an anecdote that involved a teacher who inspected the wrists and arms of students prior to a test. He wanted to ensure that students didn’t have accoutrements on their arms that could contribute to cheating. This girl said that she felt anxious about rolling up her sleeves because of the scars on her wrists and arms from cutting. What would her teacher say or do?

When he inspected her arms, he undoubtedly saw the scars. His response? “Okay, good. Nothing on you that will lead to cheating.” And that was it. He never spoke to her about what he saw; he never asked her how she was doing or what the injuries were on her arms.

What did she take away from that? “He cared more about whether I was cheating than about me staying alive.”

The fresh candor of young people inspired some adults to comment on their own perspectives of suicide. One man, hands stuffed into the pockets of his jeans and voice deep and gruff, shared, “I’m a veteran. I also come from a generation of men who just don’t talk about suicide, even though a lot of veterans come home from war and commit suicide.”

The contrast was striking: The young people sat on the stage, the lights on their faces, and spoke about death and suicide without fear or self-consciousness. The adults sat in the shade of the auditorium and shifted with unease, gasped with sadness, or shook their heads when they heard the youth talk about their peers dying.

I do not believe that there was anything anomalous about this group of young people. Youth want to talk with adults about death, dying, and suicide. They want relationships with parents and other parental figures where they can ask questions, share their worries, and learn how to navigate the difficulties in life so that they can live another day. They also are sensitive to the burdens that adults already experience; sometimes they don’t share their thoughts, worries, dreams, and fears with us because they don’t want to cause us more distress. Because they automatically assume that any conversation about death and dying will cause distress in adults.

I created a short handout with suggestions about how to talk about suicide with young people (hint: these suggestions work with adults and older people, too). It also has phone numbers to call, online chats to access, and websites to view for more information about suicide prevention.

There is no evidence to support the fear that talking about suicide—particularly in a thoughtful, caring way—will increase the likelihood that people will kill themselves. In fact, talking about suicide directly can help people change their minds about taking their lives.

Here’s the requisite link to the National Suicide Prevention Lifeline, which is an excellent and literally lifesaving resource. However, I encourage all of us to talk with each other, within our own communities—even if it is “only” the community within our homes—about death, dying, and suicide. We don’t have to talk about it all the time; we don’t have to ask each other, “Are you thinking about killing yourself?” every day. The more comfort we have with talking about how we are doing, what we’re thinking about, and what death means to us, the more we can support each other when the difficulties, problems, and failures in life occur.

Categories
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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Informal-curriculum Nonfiction Reflection

Bias.

“I’ve been alive for too long,” he sighed. “I will be 200 years old in two months and four days. I was born in 1817, you know.”

“200 years is a long time,” I replied. While he wasn’t 199 years old, the wrinkles around his eyes, the knobbiness of the knuckles on his hand, and his slumped posture made him look older than his actual age.

“I’m an angel,” he continued. “I do what I can to help people, as that is my mission from God.” His thin frame quivered as he coughed into the crook of his elbow. “God sent me down from heaven 200 years ago. People are drawn to me. Animals are drawn to me. They know that I can help them. I give away my food, I give away my cigarettes, I give away my marijuana. God gives me instructions about how to best help people.”

“Would you miss God’s voice if it went away?”

The Angel bit his thin lip before responding. “Maybe.” He looked worried.

“You seem to appreciate the guidance,” I said, though we both recognized that I was actually asking a question.

“Sometimes God says helpful things,” the Angel answered. “Sometimes… not.”

He shared that sometimes demons speak to him, too. They whisper and shout amidst his thoughts, pointing out how his efforts are useless, that no one cares, that there is no value to his life.

“What has stopped you from killing yourself?”

The question had barely left my lips before he answered, “It’s a sin.”

The cases of beer helped to mute the voices of God and the demons, which often became a cacophony when the light of heaven was gone. No, he didn’t think that the beer was hurting his liver; maybe it was even helping it.

“I didn’t get the hepatitis from drugs,” the Angel offered. “I wasn’t feeling good, I was sick. The doctor tested me and said I had hepatitis. He told me that I had to tell anyone I was having relations with. When I told the lady I was seeing at the time, she said, ‘You got that from me.’ I wish she had told me that sooner. I would’ve used protection if I had known that.”

The Angel didn’t know when he was getting out of jail. We discussed what treatment would best help him. When I asked if he had any questions for me, he shook his head.

“Feel free to come back any time to talk,” he said with the same polite manner he showed for the half hour we spoke. He bowed his head.

You can look up an inmate’s charges on the internet. It’s public information. You won’t learn what specifically happened that resulted in the arrest, but you will learn the alleged reason for why the person is in jail: Robbery. Assault. Failure to appear for court. Theft. Domestic violence.

I don’t seek that information before I meet my patients in jail. If patients start sharing their understanding as to why they’re incarcerated, I stop them. My duty is to the patient, not to the court or the attorneys.

When I first started working in the jail, I looked up the charges for all of my patients, as that information has the potential to help with clinical care. What I saw quickly dissuaded me from doing this on a routine basis.

It is uncommon for a man of the Angel’s age to be in jail. Yes, he was reporting and demonstrating psychiatric symptoms, but they alone did not explain why he captured the attention of law enforcement. Why would a man with his gentle manner and feeble condition be in jail?

Failure to report: sex offender.

The Angel had two convictions: One for Rape, the other for Indecent Liberties With Forcible Compulsion. These occurred years apart.

“Sometimes God says helpful things,” the Angel answered. “Sometimes… not.”