Category: Reflection

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Medicine Nonfiction Observations Reflection Systems

What Doctors Look Like.

I don’t remember her name, but I do remember her light brown hair, the simple nose ring that looped out of her left nostril, and the calm and centered presence she had with patients. She came across as unassuming, professional, and caring. We were both in medical school, though she was two years behind me. I admired how she treated people.

I don’t remember his name, but I do remember that he worked as a nephrologist (kidney specialist). He had a slight paunch and frequently wore dress shirts with short sleeves. The knots of his neckties were always loose. Students regarded him as an excellent teacher who revealed the mysteries of the kidney with tireless enthusiasm.

The nephrologist and I, among others, taught a course for junior medical students. Someone praised the bedside manner of this calm and centered medical student. The nephrologist interjected, “That might be true, but she doesn’t look professional. It’s the nose ring. Physicians shouldn’t have nose rings.”

I didn’t say anything in response. He was still an attending physician and I was just a medical student. His comment struck me: Did it really matter what doctors look like?

I have thought about that snippet over the years. Did he ever give her that feedback ? If he did, how did she take it? Did anyone else find his remark curious? Did any of the other attending physicians disagree with him? If they did, why didn’t they speak up?

After I became an attending physician and navigated ongoing perceptions of what I “should” look like, more questions have come to mind:

What if the medical student was a white male and had a nose ring? Would the nephrologist have made that comment? (Probably?)

What if the medical student was a stellar student and demonstrated clinical excellence? (My impression is that she did well in her coursework and that the comment about her nose ring was in the vein of, “If only she didn’t have the nose ring….”)

What if the medical student wore the nose ring for cultural reasons? Would that have mattered to the nephrologist?

What if the nephrologist learned that certain populations of patients were more likely to trust her than with him because of the nose ring?

What did the nephrologist think doctors should look like? (Clearly, he did not think they should wear nose rings.) How did he learn what doctors should look like? Who determined the definition of “professional” in the world of medicine?

Did it really matter what doctors look like? To medical students, of course it did. When we started our clinical rotations, we saw the attire of resident and attending physicians: Think Banana Republic or J. Crew, with the requisite long white coat on top. So what did we all do? We started shopping for “professional clothes”, except few of us had the money to buy stuff from Banana Republic or J. Crew. We cobbled together outfits from shops we could afford.

The pressure to conform, however, went beyond what we wore. There was only one female trauma surgeon who worked with medical students and, while students spoke well of her, resident physicians sometimes remarked that she was “too emotional”. During operations, male surgery fellows told female medical students, “You should feel this lung now, since you’re probably going to go into pediatrics or family practice.” Many of the attending physicians were heterosexual white males. Those of us who were not—men of color, women with or without nose rings, those who identified as LGBTQ—navigated how to conform to the values and behaviors of heterosexual white males, such as the nephrologist. Though some of these values and behaviors have no clinical relevance (e.g., wearing a nose ring does not affect how a physician washes her hands, gathers a history, or conducts a physical exam), they do affect how one goes through medical training. If enough attending physicians make comments about the nose ring, you might stop wearing it, even though the nose ring is something you value as a person.

What do you do, though, when the issue isn’t a nose ring, but your skin color? sex? accent? sexual orientation? culture?

When surveying the community, many people comment that they feel more comfortable working with health care professionals who look like and share the same experiences as them. Many women, for example, prefer to work with female gynecologists. People who speak languages other than English often feel more comfortable working with physicians who also speak the same language. Americans who are not white often comment that it is often easier to talk with non-white physicians about health concerns.

People with tattoos and nose rings may find it easier to talk with a physician with a nose ring. If the goal is to help keep people healthy and living the lives they want to lead, is it fair to say that nose rings are unprofessional? If the physician with a nose ring is able to connect with her patients and thus serves her community, should we indoctrinate her with the idea that nose rings are unprofessional?

Out of habit I still wear slacks and dress shirts when I see patients. I was trained that I should dress a certain way to both show respect to my patients and demonstrate that I am a professional.

The only time I did not routinely dress in slacks and dress shirts was during my time doing outreach to people who were sleeping outside. Part of this was due to function—it’s much easier to jump over puddles and slide past chainlink fences in jeans and a sweatshirt—but part of this was also because a doctorly outfit was often a liability in these settings.

How would you react if, while eating lunch outside, someone wearing a white coat and a stethoscope around her neck came up to you and asked, “Hi. How are you doing? Are you okay?”

Feedback I often received throughout my medical training (and continue to receive now) is that I do not speak up enough during rounds and related meetings.[1. Even though this post is over one thousand words, it’s true: I actually don’t talk much when working.] My seeming reticence partly reflects my introversion; it also reflects Chinese Confucian values. Medicine has trained me to talk more. I will never know if my taciturn tendencies have caused more problems for my patients (I hope not), though we all appreciate someone who is willing to listen.

And while I am sure that the nephrologist would have disapproved of unnatural hair colors, I can’t count the number of times vulnerable people with significant psychiatric symptoms were willing to talk to me simply because of my locks of curious color. This holds true even for people without any psychiatric symptoms.

I trust that the medical student who wore the nose ring has become a fantastic physician. I wonder if she still wears a nose ring. I hope she still does.

One way we recognize physicians is by their white coats. The rest of it—sex, skin color, accents, nose rings, tattoos, hair color, age, height, weight, etc.—shouldn’t matter.

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Medicine Nonfiction Reflection

On Trusting Doctors.

There exists a particular physician who many in medicine regard as a quack: She has argued that HIV does not cause AIDS. She has written many pieces stating that vaccines are toxic and cause diseases such as autism, depression, and SIDS (sudden infant death syndrome). Within certain circles she enjoys great popularity. Her medical doctor credential lends her an authority that these circles highlight in their efforts to denigrate medicine.

I know her. Our paths crossed at one point during our medical educations. At that time, she and I worked in the same hospitals and saw people who experienced not only profound illness, but also suffering related to poverty, violence, racism, and other factors that impact health.

At that time, she believed the science that HIV causes AIDS. We never talked about vaccines, but I know that she believed the science of immunology and molecular biology. She and I, along with others in our cohort, exercised critical thinking when reading and discussing journal articles.

She and I were never close, but we were friendly. She was the first person to acknowledge my engagement. We were sitting across a table while someone gave a lecture. She pointed at her fourth finger, then pointed at mine, now adorned with a ring, and gave me a bright smile.

Many years have passed since we last saw each other. I wonder what happened to her.

To be fair, our beliefs and practices share some overlap: She apparently doesn’t prescribe medications at all. I try to avoid prescribing medications when possible. She has reportedly helped people come off of medications. I have, too. She encourages the application of exercise and other nonpharmacological interventions. I do, too.

From what I can tell, those are the few characteristics we now share.

If I am honest, I feel more anger than disappointment about her practice. As I understand it, she apparently charges over $4,000 (yes, over four thousand dollars) for an initial evaluation (that lasts for two hours) and one follow-up appointment. Every 45-minute follow-up thereafter costs almost $600. It also sounds like that people who wish to see her must fill out a questionnaire, which she uses to screen people into or out of her practice.

How many people can afford to pay $4,000 for an initial evaluation? Yes, I understand how scarcity makes something or someone seem more valuable, but $4,000? People who can pay that amount—plus the $500+ for each follow-up appointment—have access to other resources that make options other than medication possible. Furthermore, if her screening questionnaire weeds out people who want (or need) to take medication, that means she is unlikely to see people with moderate to severe symptoms.

Most people don’t want to take medications. Most people try everything they can with the resources they have before seeing a doctor. Unfortunately, the current healthcare system drives and rewards physicians for prescribing medications, even when that isn’t the optimal intervention.

Furthermore, this $4,000+ results in the potential spread of false information. I don’t know what she’s doing during that initial assessment—my guess is that it involves a lot of listening—though I doubt she’s persuading everyone to avoid vaccines or that HIV doesn’t cause AIDS. I don’t know; maybe she is. Though, given her popularity in certain circles, selection and confirmation biases are already active: Only those individuals who already share these beliefs would seek care with her.

As much as the above bothers me, what irks me the most is the seeming waste of her training and talent. Our training paths crossed, yes, but look how they have diverged! She charges literally thousands of dollars to provide care for people who are unlikely to experience significant symptoms. Given the economics of her model, most of the people she sees are likely upper middle class to upper class white people.

The individuals under my care, both past and present, are often people of color with significant symptoms who have few resources, often through no fault of their own. For those who don’t wish to take medicine, we work together to help them obtain a job, secure housing, or avoid the attention of the police. Those individuals who take medicine often find that their quality of life improves by leaps and bounds: They are able to stay out of the hospital. They remain employed. They spend time doing the things that matter to them.

To be clear, upper middle class and upper class white people also experience severe psychiatric conditions. Major psychotic, mood, and substance use disorders don’t discriminate. People without money and access to resources, though, are likely to fall farther and have a harder time catching up once symptoms appear.

Let’s assume for the moment that this particular physician who charges $4,000+ for an evaluation has developed a treatment model that really helps people without the use of pharmacology. Why not share that model? Why not work with researchers and other physicians who can adapt this model to people who can “only” afford $500 for an initial consultation? Or $100? Or $5?

This physician knows how to work with and provide successful treatment to individuals with major mood and psychotic disorders. I’ve seen her work. While I have no doubt that the individuals who are able to spend $4,000 on an initial evaluation are suffering, what about all the other people who suffer who will never be able to afford that consultation? If the treatment model really works, why limit it only to the people who have that kind of money?

Why not ease the suffering of as many people as possible?

Could it be that the powers of confirmation bias, scarcity, and placebo are the keys behind her treatment model? That $4,000+ buys chiefly status and expectation? Does it matter that unfounded, dangerous claims are part of the deal?

Should you always trust a doctor?

Categories
Nonfiction Observations Reflection

Patients in a Resuscitation Room.

I didn’t post anything here last week because my dad, while walking, was hit by a car. (He is feeling better, thank you.)

When I arrived, my father occupied one of four beds in a resuscitation room. The other three beds were empty. It was still early in the morning and there were few people in the emergency department.

As the day wore on, other patients were wheeled into and out of the room. A pale yellow curtain with a floral motif enclosed the space around each patient. The patients and their visitors caught glimpses of each other whenever the ED staff pulled the curtains open.

While curtains provide visual privacy, they are not soundproof.

An inmate from the local jail came in with chest pain. He shared his entire medical history with his accompanying jail officer. After listening to the inmate’s monologue for about five minutes, the officer interjected, “I’m going to watch this TV show now.” The inmate, along with the rest of us, listened to what sounded like an action movie. The inmate sounded more disappointed than relieved when he learned that he did not need to stay in the hospital. He went back to jail.

A mother and father came in for reasons I never learned. Their young toddler with enormous eyes grasped the pale yellow curtain in her tiny fists as she explored both sides of the boundary. Their infant stopped wailing when the mother sang, her voice full and calm. When the family left, they took the laughter with them.

A woman with dark pink hair was wheeled in. Another car hit her while she was driving. Her voice was light and melodic as she expressed profuse thanks to the medics. Her voice cracked as she spoke to a friend on the phone: Was she ever going to get a break? Why did her friend hit her with the car? Why was this the third time in her life she was in a car crash? What if she never got sensation back in her leg? Why did she have so much bad luck? After she hung up the phone, she wept. She took her frustration out on the nurse. No one was at her bedside.

A slender man was wheeled in. He, too, was in a car crash. His answers to questions were short and quiet. The sadness on his face could have been new, though the wrinkles around his lips and eyes hinted that maybe he wore a sad face most days. He stared up at the ceiling. No one visited him.

My mother came into the room, too. My father recalled when he was last in an emergency department: His wife was short of breath and feeling exhausted. He remembered the week she spent in the hospital, all the questions, poking, and testing she had to endure, and how much she hated it.

“Now I understand why she didn’t like the hospital,” he murmured. The edge of the pale yellow curtain shifted, though no one was there.

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Homelessness Lessons Nonfiction Observations Reflection

What Would It Be Like to Say Hello?

My first memory of encountering a person who appeared to have no place to live was during my first year of college at UCLA. A man was sitting outside a mini-mart, his legs crossed and his hair long. He looked tired and his clothes had stains on them. Feeling pity for him, I went into the mini-mart and purchased a turkey sandwich on wheat.

“Here,” I said as I handed him the sandwich. I beamed with Warm Fuzzies for Doing a Good Deed. “Take this.”

Because I expected him to thank me for My Act of Generosity, I was dumbfounded when he started yelling at me with contempt: “A sandwich? I don’t want that sandwich. I don’t like turkey and I have an allergy to gluten. If you really wanted to help me, you’d buy me a meal at an all-you-can-eat place. What am I going to do after I eat a sandwich? I’ll still be hungry. At least I can get another plate of food at an all-you-can-eat restaurant.”

“Okay,” I said, my cheeks burning with shame. He had a point: All hungry people prefer all-you-can-eat food to what now looked like a pathetic turkey sandwich. I took the rejected sandwich back to my dorm room.

My dining companion and I were seated at a long table that looked out a large window. Across the street was a man who we often saw in the downtown shopping district. He often carried a unrolled sleeping bag on his shoulder while talking and growling to himself. His clothes were soiled and too big for him. The soles of his shoes were falling apart. He didn’t have a beard, only uneven facial stubble. His eyes were light and his face was dark from smears, smudges, dirt, and dust.

“He doesn’t look well,” I said to my dining companion. The man was sitting on his rumpled sleeping bag on the sidewalk while engaged in an animated conversation… with no one. Sometimes he leaned back against the side of the building and puffed on a cigarette.

“I wonder when he last ate,” I wondered aloud.

“Why don’t you buy him something to eat?”

“Because he might not want that. Some people feel shame when people just give them food. They don’t like that other people think that they don’t have enough money to buy food for themselves. And I don’t even know what kind of food he wants. When we’re done eating, let’s go over there and ask him.”

As we approached him, his posture was relaxed and he was about halfway through his cigarette. His clumpy hair was falling into his eyes and everything he was wearing was soiled. He was engrossed in a conversation, occasionally making a point with his right hand.

“Excuse me?” I asked.

He continued talking.

“Excuse me?”

He stopped talking, turned his head, and looked at me. He remained still as the swirls of smoke from his cigarette defied gravity with ease.

“Hi. Do you want some food?”

Another tendril of smoke dissolved into the night before he answered: He shook his head no.

“Are you sure?”

He nodded yes.

I smiled and waved good-bye. I heard him resume his conversation as we walked away.

In retrospect, I should have introduced myself and asked him for his name. And I wonder if, next time, he will be hungry and accept an offer of food.

Sometimes we believe people are so different from us. How could there be anything similar between that guy talking to himself and sleeping on the street and me? What do I have in common with that guy wearing dirty clothes and carrying a sleeping bag around?

Well, we all share the wish to be treated with dignity. We want people to acknowledge us, our presence, our existence. We want people to see us as equals, not less than. We want people to show us respect, to see us as people who have worth.

Maybe you see someone in your daily commute who sleeps outside or doesn’t seem to have any money. Maybe it’s someone who sits against a wall with a sign asking for help.

What would it be like if you said hello that person? Or made eye contact with that person and smiled? What would it be like to acknowledge that person as a person? What’s gotten in the way of you doing that in the past? What is the worst thing that could happen if you tried that? What’s the likelihood that your worst fear in this situation would come true?

What would it be like if we said hello to everyone in our communities? Because aren’t these individuals who sleep outside and talk to themselves part of our communities?

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Funding Homelessness Nonfiction NYC Policy Reflection Seattle Systems

God’s Work versus Meaningful Work versus Value.

Every now and then, when some people learn what kind of work I do, they say, “You’re doing God’s work. Thank you.”

They mean well, so I accept the compliment, though I also tack on, “I also like what I do. It’s meaningful work for me.”

So many of the people I see, whether in my current job or in my past jobs working in other underserved communities, have a lot going on that psychiatry and medicine cannot formally address. One example is housing. It is often an effective intervention for the distress of people who don’t have a place to live, though housing is not something physicians can prescribe. However, there are individuals who are eligible for housing, but do not want to move into housing for reasons that do not make sense to most people. For example, in New York I worked with a man who would spend his days sitting in front of the building where he once worked before he became ill. He talked to himself and burned through multiple packs of cigarettes. He did not recognize how soiled his clothes and skin became with time. At night he disappeared into the subway tunnels and rode the trains. He did not want to move into an apartment until he was able to get his job back, even though he hadn’t worked there in over ten years. With time (nearly two years!) and unrelenting attention, our team was able to persuade him to try living indoors. He eventually accepted the key and moved in.

There are other active conditions that I do not have the skills to treat: Sometimes it’s institutional racism; sometimes it’s multiple generations of poverty. Both prevent people from accessing education, housing, and other resources. Do some of these individuals end up taking psychotropic medications due to the consequences of these systemic conditions? Yes. Do I think they’re always indicated? No.

Most of my jobs have been unconventional: I worked on an Assertive Community Treatment team that often provided intensive psychiatric services in people’s homes. I worked with a homeless outreach team and did most of my clinical work in alleys, under bridges, and in public parks. I worked in a geriatric adult home and saw people either in my office, which was literally the storage room for the recreational therapist’s stuff, or in their apartments if they were uncomfortable seeing me in the storage room. I was recruited to create and lead the programming for a new crisis center whose goal was to divert people from jails and emergency departments.

And now I work in a jail.

As time progresses, it has become clear to me that I have not had the typical career for a psychiatrist. I like that. However, I often also feel out of touch with my colleagues. I believe that they are all trying their best, but they don’t have the time to see how systems end up failing the most vulnerable and ill in our communities. They work in the ivory towers of academia and don’t seem to realize the dearth of resources—financial, administrative, academic—in the community. They work in private practice and don’t seem to realize how ill some people are and how we need their expertise. They work in psychiatric hospitals and seem to believe that some of these individuals will never get better when, in fact, they do.

Because much of my work has been outside of the traditional system, I consider myself fortunate that I have been able to escape the box of simply prescribing medications. Many of the individuals under my care do not want to take medications. Their desire to not take medications, though, doesn’t stop us from working with them. We meet them where they are at and remember that they are, first, people. As we are in the profession of helping people shift their thoughts, emotions, and behaviors, we believe that there will come a time—maybe soon, but maybe not for weeks, months, or years—that something will change. Just getting someone to talk to us becomes the essential task. This is true whether someone is in a jail cell, living in a cardboard box under a bridge, or residing in a studio apartment.

Should systems pay psychiatrists to do this work? Maybe it’s not “cost effective” because of its “low return on investment”. After all, this task of “building rapport” means psychiatrists aren’t working “at the top of their licenses”. If a psychiatrist is able to get people to talk to her and help them shift their behaviors, whether or not that involves medications, does that have value?

Does the psychiatrist’s efforts have value if it helps the “system” save money?

Is there value if it reduces the suffering of these individuals who have had to deal with police officers, jails, and living on the streets due to a psychiatric condition?

Perhaps my idealism blinds me. One of my early mentors in New York City often said, “I want the guy who lives under the Manhattan Bridge to have a psychiatrist who is as good as, if not better than, the psychiatrist who has a private practice on Fifth Avenue.” I couldn’t agree more.