Category: Reflection

Categories
Consult-Liaison Education Medicine Observations Reflection

Pay It Forward.

Prior to starting medical school, I had no desire to work as a psychiatrist. I had a plan: I’d become an infectious disease physician[1. I studied microbiology and molecular genetics in college. My fondness for bacteria persists.] or an oncologist.

During my psychiatry rotation as a medical student I spent four weeks on a consult-liaison service. I worked with an attending who was smart and excellent with patients. Though everyone agreed he wasn’t warm, he was genuinely kind. (He also wore bow ties and suspenders. His clothes never had wrinkles in them. Was this due to his military background?) My plans started to change.[2. It wasn’t a single moment that made me abandon my original intention to go into internal medicine. I still remember the case, though, that tipped me to go into psychiatry: One of my patients on the medicine service was a firefighter who had suffered a significant bleed in his stomach. I was able to talk about the cells and chemistries in his blood, the risk factors that contributed to his condition, and what he could do in the future to prevent this from happening again. Yet, I couldn’t tell anyone anything about him as a person, how he came to have those risk factors, how he perceived those risk factors, and if he had any desire or intentions to change his behaviors so that he could prevent this form happening again.]

Before starting my psychiatry residency, I had no particular interest in working with people experiencing psychotic symptoms (e.g., hearing voices, holding firm beliefs that are not rooted in reality, etc.). I had a plan: I’d become a consult-liaison psychiatrist and spend my days in hospitals spanning the boundary between acute medical care and psychiatry. There was a little of everything in consult-liaison psychiatry: the full spectrum of psychiatric conditions; brief psychotherapy; teaching patients, families, and, often, the staff of the primary medical service; starting and stopping medications to reduce distressing symptoms.

During my residency I found myself finding the most meaning when providing care to people with limited means: refugees from Southeast Asian countries; military veterans with few supports upon their return from wars ranging from World War II to the wars in Iraq and Afghanistan; people living in homeless shelters or on the streets. Medications were not always useful or indicated. The senior residents and attendings in these settings were astute, unpretentious, compassionate, and just good with people. My plans started to change.

Now, as an attending, my interests are a mix of all those things: I like working with people with significant psychiatric symptoms who often have limited means. I like working in teams to help people get better and out of the system, whether that is the hospital, the jail, or the mental health system entirely.

I spent over eight years of medical training under the supervision of “attendings”. It took me a few years to get used to people calling me “Dr. Yang”.[3. I still find it jarring when colleagues who routinely call me “Maria” suddenly address me as “Dr. Yang”.] I guess I’m not yet used to the idea that I am now an attending and people expect me to “know”:

  • a high school student who wants to interview me to ask about my work as a psychiatrist
  • college students who want to learn more about non-traditional work in psychiatry[4. Thanks for helping to inspire this post, Anna!]
  • medical students who want to know which psychiatry residencies they should apply to if they want specific training in working with indigent populations
  • residents who want to know which fellowships they should apply to if they are interested in public sector clinical and administrative duties
  • fellows who want to know where they should apply for work in non-traditional settings

It’s weird. Impostor syndrome persists: These people think I’m qualified to tell them?

When I think about all the people who guided me—intentionally or not—to where I am today, I find that the second best way to thank them is to pay it forward.[5. The first best way to thank people, of course, is to directly thank them for the specific things they said or did.] We need people who have the will and energy to serve the community, who are willing to think about and do things differently. Yes, interests change, plans change, people change. However, we never know how our words and actions may inspire those around us.

Categories
Consult-Liaison Education Informal-curriculum Medicine Nonfiction Observations Reflection

Teaching Moment.

The Chief of Service ushered me into the room, but said nothing. His staff of fifteen looked at the Chief with expectation and, upon realizing that he was looking at me and probably wasn’t go to say anything—including my name or the reason for my visit—the fifteen people joined him in looking at me.

“Hi,” I said, taking the cue and flashing The Winning Smile. This is my name, this is my title, and this is why I’m here: As a psychiatrist, I think there is overlap in the work that we do and in the patients that we see—

“Is it okay if we refer to your patients as ‘wackos’?” the Chief blurted out. Nervous laughter twittered among his staff.

“I’d prefer that you didn’t.” My voice was light; my face was dark.

“Oh. I guess another psychiatrist should have told me that.” He was still smiling.

“I hope I’m not the first one to do so.” When he finally saw the lasers shooting from my eyes, his smile dissolved and he looked down.

There are several reasons why I believe that social skills are not his forte:

  • He either chose not to or did not think he needed to introduce me to his staff.
  • As a Chief of Service he should have known better than to say such things in front of his entire staff.
  • This exchange occurred within five minutes of us meeting each other.

I think his question—“Is it okay if we refer to your patients as ‘wackos’?”—was his honest effort to connect his staff and me together. Everyone would have a good laugh, we’d share something in common, and we could move forward with greater ease. He thought his comment was benign.

It makes me wonder, though: Had he made a similar comment in the past to another psychiatrist? And had that psychiatrist laughed? Did a ridiculous repartee follow?

Did another psychiatrist reinforce this sort of behavior?

He’s not a “schizophrenic”. He’s a guy with a diagnosis of schizophrenia. Maybe he’s even a guy who is skilled guitar player, a father of two children, and has a degree in political science who happens to have a diagnosis of schizophrenia.

She’s not a “brittle diabetic”. She’s a woman with a diagnosis of diabetes. Maybe she has a knack for training dogs, has a remarkable talent for singing, and was on her way to law school when she was first diagnosed with diabetes.

People are people with various interests, talents, and potentials. They are not their medical conditions.

No one is a “wacko”.

The Chief of Service sent me an e-mail later:

Thank you for visiting us and also for your gentle way of reminding me of my crudeness and insensitivity. I am sure you hear enough negative attitudes towards your clients that you would welcome the opportunity to create a more positive attitude towards mental health issues.

I actually don’t hear many “negative attitudes” about my patients. Perhaps this is because every moment can be a teaching moment and, over time, people learn not to use such language (at least around me). As I noted several years ago:

Doc­tors, like most peo­ple, often assign adjec­tives to patients because it can be hard to iden­tify and then acknowl­edge emo­tions. It is much eas­ier to say, “She is such a dif­fi­cult patient! She is never happy with her care!” than to say, “I feel angry and help­less when I see her because it seems like noth­ing improves her symp­toms!” Leav­ing out the sub­jec­tive “I” gives the illu­sion of objec­tiv­ity and professionalism.

I can only hope that the Chief of Service shared his reflection about his “crudeness and insensitivity” with his staff.

Categories
Observations Reading Reflection

Recent Readings.

Things I have recently read (with commentary on only one piece):

The Stranger Beside Me

I have a longstanding interest in serial killers because I have no understanding why they murder people. My hope is that, upon finishing a book like this, I can make more sense out of something I just don’t get.

I didn’t realize that Ted Bundy had a history in Seattle. He was a work-study student at our local Crisis Clinic. He also worked with psychiatric patients in the clinic at Harborview Medical Center, the de facto county hospital. He murdered women in King County.

The author of The Stranger Beside Me had a friendship with Ted Bundy. She was writing the book as he was murdering women. While I did not gain a greater understanding why Ted Bundy killed people when I finished her book, I did appreciate her efforts in describing Ted Bundy as a person and her internal struggles as she wondered if her friend was the man responsible for many murders.

Solitude and Leadership

“What we have now are the greatest technocrats the world has ever seen, people who have been trained to be incredibly good at one specific thing, but who have no interest in anything beyond their area of exper­tise. What we don’t have are leaders.”

Rethinking Work

“But we care about more than money. We want work that is challenging and engaging, that enables us to exercise some discretion and control over what we do, and that provides us opportunities to learn and grow. We want to work with colleagues we respect and with supervisors who respect us. Most of all, we want work that is meaningful — that makes a difference to other people and thus ennobles us in at least some small way.”

Placebo Effects in Medicine

“Unfortunately, much of what is known about placebo effects has been discovered through laboratory experiments with healthy volunteers, employing deceptive techniques that are not directly pertinent to clinical practice. We need more research involving clinical interventions designed to elicit placebo effects in participants without deception and in a manner consistent with informed consent.”

Some Thoughts on the Real World by One Who Glimpsed It and Fled

“Creating a life that reflects your values and satisfies your soul is a rare achievement. In a culture that relentlessly promotes avarice and excess as the good life, a person happy doing his own work is usually considered an eccentric, if not a subversive.”

Categories
Consult-Liaison Reflection

Questions about the Throwing of Urine.

If a man throws an open container of his own urine at another person, does he have a mental illness?

  • What if he throws an open container of water at another person?
  • What if he throws a closed container of his own urine at another person?

If a man throws an open container of his own urine at a nurse in a hospital, does he have a mental illness?

  • What if he throws his urine at a nurse who is trying to inject him with a medication he doesn’t want?
  • What if he throws his urine at a nurse who is trying to give him food and drink?

If a man throws an open container of his own urine at a nurse on a surgical ward, does he have a mental illness?

  • What if he throws his urine at a nurse while on a psychiatric ward?
  • What if he throws his urine at a nurse while in jail?

If a man throws an open container of his own urine at the police when they charge into his home, does he have a mental illness?

  • What if he throws his urine at the police because he has multiple containers holding his urine and those are the closest things he can grab?
  • What if he throws his urine at the police because he hates the police?
  • What if he throws his urine at the police because he hears voices that tell him to do this to protect himself?

If a man collects his urine into a container over time for the purpose of throwing it at another person, does he have a mental illness?

  • What if he believes his urine is holy water and believes that his urine will baptize others and save their souls?
  • What if he wants to witness the anger and disgust of others when his urine splashes all over their faces?

If a man throws an open container of his own urine at himself, does he have a mental illness?

  • What if he throws his urine on himself because he is in solitary confinement and cannot throw the urine at the person he is angry with?
  • What if he throws his urine on himself because he is in solitary confinement and this is the only way he can have contact with another person?

If a man throws an open container of his own urine at another person, does he have a mental illness? or is he just a jerk?

Categories
Education Observations Reflection

A Review of Inside Out by Pixar.

Like others, I saw the Pixar film Inside Out and I, too, recommend it. Drs. Keltner and Ekman[1. Paul Ekman is the guy who studies the expressions of emotions on faces and their universality.], the psychologists who provided consultation to Pixar about the film, were incisive about the point of the story:

“Inside Out” offers a new approach to sadness. Its central insight: Embrace sadness, let it unfold, engage patiently with a preteen’s emotional struggles. Sadness will clarify what has been lost (childhood) and move the family toward what is to be gained: the foundations of new identities, for children and parents alike.

The film demonstrated in colorful and delightful ways how emotions interact with each other; how memories are created, moved, and stored (the marble imagery was both beautiful and fun); and how emotions, thoughts, and behaviors can interact with each other. Parents may wish to bring tissue; all the adults around me (and me, too) audibly cried at least once during the movie.

If you haven’t seen the film yet, please note that the rest of this post has spoilers in it. You have been warned.

Some other observations of the film:

Like others, I didn’t like how Sadness was portrayed in the film. I do not protest that she was the color blue; I do wish she wasn’t portrayed as lumpy, lazy, and lethargic. (At several points in the film, Joy literally drags Sadness around.) While sadness can make us feel listless and inert, sadness often motivates us to take action. Sadness is ultimately redeemed in the film: The family becomes and feel more connected because of the introspection and action Sadness fosters. However, I don’t think Sadness should have been thrown under the bus in the first place.

It is also noteworthy that Sadness is portrayed as female. One wonders if Sadness would have been portrayed as lumpy, lazy, and lethargic if the character were male. Is this social commentary on the perceived “moodiness” of women?[2. Just to be clear, I do not equate “moodiness” to “depression”. Others sometimes do.]

Of course, sometimes a cigar is just a cigar.

The “leader” of the emotions in the mother’s head is Sadness (looking sharp in a business suit, no less!). This choice may have been a foreshadowing device: The mother demonstrates skillful parenting in the film, which hints at the organizing power of sadness. This again suggests that sadness has value and helps us connect with others in meaningful ways, as parents or not.

The film uses the model that thoughts occur as a consequence of emotions. Emotions come “first”. Champions of cognitive therapy[3. Related: Cognitive behavioral therapy may be losing its effectiveness over time. One complaint many people have had about CBT is that the process can feel invalidating: “So… you’re just saying that I think the ‘wrong’ things. If I only thought the ‘right’ things, then I wouldn’t feel this way. So you’re saying it’s all my fault. Thanks a lot, jerk.”] would disagree with this: They would argue that thoughts always precede emotions, even when we have no idea why we feel the way we do.

This is one of many hypotheses about our internal experiences. Other models concur with the film’s assertions that emotions have primacy; our behaviors and thoughts can be consequences of what we feel. I believe that they are ultimately all related and each can have primacy, depending on the circumstances.[4. This isn’t entirely related to the primacy of thoughts, but someone, who I now can’t remember, said something pithy like, “Who are you between your thoughts?”]

There are delightful visual puns in the movie. One that I thought could use elaboration was the “train of thought”. The train in the film didn’t serve much purpose other than as a literal means of transportation for the emotions. Pursuing more meaning in the train may have derailed the film, so I understand why the train of thought was left as a train. It, however, might have been an opportunity to explicitly describe the interactions between thoughts, emotions, and behaviors.

I do recommend the film to adults and children alike. It offers a refreshing counterpoint to the messages we usually get from society about sadness (e.g., feeling sad means that there’s something wrong with you; you should try to avoid feeling sad as much as possible; etc.). When we embrace those emotions we often want to avoid, we learn more about ourselves, what steps we can take next, and the value of our internal lives. Pixar does an excellent job of teaching us these lessons in a fun and colorful way.