Category: Reflection

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Lessons Medicine Reflection Systems

Reflections on Psychiatry.

A medical student named Anthony sent me an e-mail and asked:

Are [the items listed below] things that have nagged at you during your training or as a psychiatrist now? How do you deal with the ambiguity of psychiatry, or do you find that as your clinical experience grows, you find yourself more reassured in what you do from seeing your patients improve? Where do you see psychiatry going in the next couple of decades? I understand these are big questions, but I feel it would be incredibly helpful to hear from someone who’s been practicing for a while.

Indeed, these are big questions, but the big questions make us reflect on what we do: What is the point? Why do we bother? Are we doing the “right” thing?

Are these things that have nagged at you during your training or as a psychiatrist now?

The things Anthony listed as frustrations—the primacy of the biological model, the lack of novel and consistently effective medications, the role of medications and pharmaceutical companies, the medicalization of “normal” human experience—resonate with me, too. These things bothered me while I was in medical school, irritated me when I was a resident, and continue to vex me as an attending.

What bothers me the most is how psychiatry can become an agent of social control. Psychiatry can lend its vocabulary and constructs to authorities to oppress or exclude certain populations.

Consider the spate of school shootings. If we label the shooters as “mentally ill”, that distracts from the culture of fear and violence. Homosexuality was a legitimate psychiatric diagnosis until 1973. African Americans are more likely to receive diagnoses of schizophrenia.

Words are powerful. The ramifications of diagnosis are serious. We must not forget how our words can affect how people perceive themselves and how others treat them.

This overlaps with the medicalization of human experience. Is it okay that people receive Xanax from physicians when they are grieving the death of a loved one? Is it okay that students receive Adderall from physicians when they are striving for academic excellence? Is it okay that people from other cultures receive antipsychotic medication from physicians when they report hearing the voices of their ancestors?

My discomfort with this has affected my practice: I purposely choose to work with people who exhibit symptoms that rarely overlap with the general spectrum of human experience. Most people do not believe that someone has stolen their internal organs. Most people do not drink a fifth of alcohol each day to cope with guilt and shame. Most people do not fear that aliens will execute them if they move into housing from the streets.

A natural consequence of working with this population is that advocacy becomes a large part of the work: People with severe conditions can and do get better. Most people enter medicine to help people, to see people get better. The gains in this population may take longer and sometimes may not be as great as in other populations, but they do occur.

How do you deal with the ambiguity of psychiatry, or do you find that as your clinical experience grows, you find yourself more reassured in what you do from seeing your patients improve?

I learned early on that, if I don’t know the answer, the best thing to do is to say, “I don’t know.” It can be hard to say that out loud because we don’t want to admit our ignorance to ourselves or to others. Perhaps the difficulty isn’t the ambiguity of psychiatry. Maybe the challenge is managing our own vulnerability.

This is how I deal with the ambiguity:

  • I remind myself that it is impossible for me—or for anyone—to know everything. That doesn’t mean I give up and walk away: I do the work to learn as much as I can. The learning never stops, even when I want it to.
  • I remind myself that I will mess up. I hope that I will make fewer mistakes as I advance in my career, but I trust that I will screw up. I also hope that I will have the wisdom and humility to learn from my errors and avoid them in the future.
  • I remind myself to “First, do no harm.” I may feel pressure[1. Know that the system will often put pressure on you to “do something”. That doesn’t mean the system is right. Unless someone is dying in that moment, there is always time to stop and think.] to “do” something—prescribe a medication! send someone to the hospital! intervene right now! There is always time to pause and consider: “Will this cause (more) harm?” To be clear, I don’t advocate living life through avoidance. Sometimes the way to navigate ambiguity is to avoid actions that will make things worse.

I’m sure this isn’t the first time you have heard an attending say this: The farther along I go the more I realize how little I know. There is so much more for me to learn.

Where do you see psychiatry going in the next couple of decades?

Experts are much better at describing base rates than they are at predicting the future.[2. This idea about base rates and predictions comes from the book Decisive, which I recommend with enthusiasm.] This is an important question that deserves more reflection. Different ideas spin in my head: Psychiatry will have to reconcile with people who have experienced mistreatment from our field. Psychiatry must examine social determinants of health and scrutinize how they affect diagnosis and treatment. Psychiatry must collaborate with other fields and cannot expect that isolation will actually help patients, our colleagues, or the specialty.

For you (and me) I would add that we cannot expect to influence or change a system if we do not take part in it.[3. Full disclosure: I am not a member of the American Psychiatric Association. My values do not seem to align with theirs. However, who am I to complain about the values of the APA if I’m not willing to help shift them? And how can I contribute to any shift if I do not join them?]

Good questions, Anthony. I encourage you to ask other psychiatrists these same questions. Regardless of which field you choose to enter, I hope you continue to exercise curiosity and healthy skepticism of the work you do. This will not only help you grow as a person and physician, but will also help your patients and field of expertise.

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?