Category: Seattle

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Nonfiction Reflection Seattle

What Makes America Great.

After a long gaze at the different fonts and bright colors, my father, a Chinese man in his 70s, concluded in English, “The menu is different.”

“Yes, it’s new. Today is the first day,” replied the clerk, a Latina woman in her 40s. Standing next to her was a young Latina woman, perhaps not yet 20 years old.

“It used to be K5,” my father murmured in Chinese.

“Do you want what you usually get?” I responded in Chinese.

Though my father has an excellent grasp of English, the new orientation and colors of the fluorescent menu perplexed him.

“Yes….”

“Chicken legs, right? You want K1.”

My dad found K1, too, and nodded with approval. He directed his attention to the cashier.

“Can I please have K1?” he asked.

The older woman nudged the younger woman to show her how to enter this order. “Ask if he wants original or extra crispy,” she advised in English.

“Original or extra crispy?” the young lady parroted.

“Original,” my dad said. The older woman then began to give instructions to the young woman in Spanish.

“It’s her first day here,” the older woman offered. The young woman smiled sheepishly; we all smiled back at her. No big deal.

And so it went: Spanish behind the counter, Chinese in front of the counter, with English connecting the two sides, and people helping people in all directions.

This is what makes America great.

Categories
Nonfiction Observations Seattle Systems

What Seattle Got From Amazon.

Yesterday’s New York Times had an article with the title “Amazon’s HQ2 Will Benefit From New York City. But What Does New York Get?” I don’t know what New York (and Crystal City) will get, but here are my observations (as someone who lived in Seattle from 2004 to 2008, and then from 2011 to now) as to what Seattle got:

Lots of young people. Some of these people look like they’re 12 years old, but that’s because I’m now officially old. And some of these young people, fresh out of college, make six-figure salaries. Sometimes it shows. Sometimes it doesn’t.

Lots of blue badges. Amazon employees wear blue badges. You can tell your proximity from the Amazon campus (which is a campus; it occupies an entire neighborhood) by the density of blue badges hanging from lanyards, dangling off of belts, and swinging off of coats.

Food trucks. The young people apparently like food trucks. Caravans of food trucks rumble towards South Lake Union, the site of the Amazon campus. The rotating food trucks sell Thai bowls, Italian sandwiches, barbecue wings, Turkish kebabs, Hawaiian poke bowls, and other international cuisines from their portable kitchens.

Hip restaurants that sell overpriced food. Here’s an anecdote that I share with some bitterness: One such restaurant has the following item on its dessert menu:

Warm chocolate chunk cookie with whole milk. $8.

Long-time readers know that I am fond of cookies, particularly the chocolate chip variety. Upon seeing this item, my eyes lit up, but the light drained from my eyes when I saw the price.

“No cookie and milk is worth $8,” I said. “Even my favorite cookie (the Levain Chocolate Chip Walnut Cookie) is just $4.”

“But what if it is the best chocolate cookie you will ever eat?” my husband countered.

“I doubt it. This is a restaurant, not a bakery.”

“Let me buy it for you.”

I relented and ordered the warm chocolate chunk cookie with whole milk, my taste buds eager and my mind skeptical.

What actually arrived? Two cookies, each about four inches in diameter, and a glass holding about six ounces of milk. The cookies were barely warm, the chocolate was not chunky, and the overall texture of the cookies was dry. The milk was wholly unremarkable. The dessert was rich only in the flavor of disappointment.

These restaurants can charge $8 for cookies and milk because they know that the young people who work at Amazon have no qualms spending such a ridiculous sum on a treat that is sweet only in memory.

Traffic. The tens of thousands of people who moved to the Seattle metropolitan area have to get around somehow. When I was a resident, I saw few taxis downtown or on Capitol Hill. Taxis of all colors now zip around the city, along with ride sharing vehicles. There are a lot more fancy cars—Teslas, Porsches, and the like—crawling up the hills. The buses, streetcars, and trains are packed with well-heeled young people.

High rents and expensive homes. The city of Seattle is in King County. The average rent in King County is $1,731, which doesn’t seem impressive compared to rents in other major metropolitan areas. The rent in King County, though, has increased 155% in the past twenty years. Furthermore, Seattle, by far, is the most expensive and developed city in the region and pulls the average up, as other areas in the county are sparsely populated and considered rural.

Income inequality. I don’t know if Amazon was/is the cause of the homelessness crisis in this region (remember, correlation does not mean causation). As young people with gobs on money have moved in, more people with little money have moved out onto the streets. Certainly the higher rents have pushed many people out of the city: Some people work in Seattle and live in neighboring counties, as that is the only way they can afford their rent or mortgage. Landlords in Seattle know that they can charge nearly $3000 for a one-bedroom apartment because someone from Amazon can afford to pay that. (Just like restaurants can charge $8 for cookies and milk.)

Anti-Amazon and anti-Jeff Bezos graffiti. It is not uncommon to see graffiti painted on sidewalks and buildings that denounce Amazon and Jeff Bezos. Some of it is frankly disturbing (e.g., death threats), though it illustrates the strong feelings people have about Amazon.

Spherical buildings. They took all the trees / And put ’em in a tree museum / And they charged the people / A dollar and a half to seem ’em

Amazon has done well for itself, though it seems that many people in Seattle have an uneasy relationship with Amazon. They like what Amazon has to offer, but don’t like how the wealth of the company has affected the city. Perhaps the leadership of New York and Crystal City will forge closer working relationships with Amazon from the outset to prevent the congestion, big income disparities, and resentment[1. The resentment that people have for Amazon also comes from its own employees. For a while I worked in a clinic where some of my patients were Amazon employees. They often spoke of the pressures working at Amazon, whether they worked in programming, marketing, supply chain, or warehousing. There’s likely selection bias at play, but their work nonetheless induced anxiety and affected their abilities to cope.] that occurred in Seattle.

Categories
Homelessness Lessons Medicine NYC Observations Reflection Seattle

The Kind of Energy We Send Out to the World.

I have been writing; I just haven’t posted anything here. These days, it seems that we cannot escape increasing types of noise and their loud volumes. It’s not all noise, but the signals are overwhelming.

It was a busy teaching week for me: I had the privilege to speak at two community clinics and a public hospital. In all three presentations I commented on the tension between “the system” and our efforts as individuals. When we’re trying to provide care and services to individuals, sometimes the constraints of “the system” interfere with our efforts: Sometimes fiscal concerns reign supreme; sometimes the bureaucracy is inflexible; sometimes the system does not have noble intentions. We grumble, we get angry, we feel helpless.

When we’re trying to design “the system” to provide care and services, sometimes the constraints of people interfere with our efforts: Sometimes there aren’t enough people; sometimes people make mistakes; sometimes people do not have noble intentions. We grumble, we get angry, we feel helpless.

The two, of course, are related: People design systems. People work within systems. People can change systems.

People also have values. Sometimes we find that our values clash with those of the systems we work and live in. That doesn’t mean that we must defer to the values of the system. It takes courage to resist. To show our values to the world without flinching is an act of bravery.

While speaking, I told a story about my first boss when I finally started working as an attending psychiatrist. Our jobs included working with people who were homeless in New York City.

“I want people who don’t have a place to live to get excellent care,” he said, perhaps talking more to himself than to me. “Good care shouldn’t be limited to people who can afford to pay a psychiatrist who works out of a plush office on Park Avenue. People who don’t have money should have access to and get good care, too.”

“These are choices under our control,” I said to the audience yesterday, perhaps talking more to myself than to them. “Even though system pressures are very real, you can choose to give good care to the people who come here for help. You can treat people with dignity and respect, particularly if they are people of color with very low incomes. They might not get dignity or respect elsewhere.”

Perhaps my exhortations sound naive. Perhaps cynicism will triumph over virtue. However, I refuse to embrace cynicism. Cynicism makes for terrible company. Life is already full of challenges; we do not need negative soundtracks to accompany us as we travel through life. What we do affects others. What we say can inspire others.

We have responsibility for the kind of energy we send out to the world.

Categories
Informal-curriculum Medicine Nonfiction Seattle

My Seattle Times Op-Ed about #MeToo in Medicine.

The Seattle Times published an op-ed I wrote! Their editorial staff provided the title, #MeToo in medicine: ‘Who would believe a trainee?’

I wonder: What if I had a different byline? Would the Seattle Times have published it if I worked as a nurse? medical student? medical assistant?

What if I worked as a janitor in a hospital? Or in housekeeping?

What if I waited tables? worked in retail? had a job that is “off the books”?

The last sentence in my op-ed is “I was fortunate, but not all women are.” I was fortunate in that I had support from supervisors and colleagues, and that the psychiatrist in question didn’t do anything worse.

I remain fortunate, though, in that I have the privilege to be able to share this story to a wider audience. I have access that other people lack. And those are the people we should consider about when we talk about “#MeToo”.

The senior psychiatry resident at the University of Washington School of Medicine warned me ahead of time. She laughed as she said, “He’s weird. You’ll get used to him.”

When I first met with him, the psychiatrist lazily spun in his chair, his left hand tucked into his pants, his thumb hanging out. After he told me his expectations as my supervisor, he patted my right thigh as he ended the meeting.

I spent one day a week training in his clinic. He often put his hand on my shoulder. If he sat near me, he extended his arm to pat my leg. When I sat far from him, he crowed compliments in front of patients and other staff: “Dr. Yang is one of the best residents who has ever worked with me!”

He began to send emails to me at all hours of the day and night. They stopped referring to clinical research and developments; now he wrote of art, history and music that he thought I would enjoy. Some of the timestamps on his emails were near 2 a.m.

“Do as I say, don’t do as I do,” he chided in his emails. “Good night.”

My discomfort increased over time, though I wondered if I was overreacting. After all, didn’t another resident tell me that he was weird? She didn’t seem distressed with his behavior. Maybe I was too sensitive.

I asked two other supervisors, both psychiatrists, for advice. The male psychiatrist was angry and swift in his response: “You have to tell your residency director. This isn’t right.”

The female psychiatrist wavered. “I don’t know,” she said after a long pause. “It’s up to you if you want to say something. It could turn into a ‘he said, she said’ issue.”

She had a point: Who would believe a trainee over a tenured professor? Would he retaliate? How would this affect the rest of my training?

I decided to talk with him first. My request seemed reasonable: “Could you please stop touching me and stop sending emails to me that are unrelated to clinical work? I feel uncomfortable when those things happen.” I rehearsed.

The next time I saw him, he greeted me with a pat on the shoulder. I felt my face flush as I stammered, “Could you please stop touching me? It makes me feel uncomfortable.”

He paused, then smiled. “Why didn’t you tell me sooner? It’s not that big of a deal. I’m just being friendly.”

It was a big deal: He stopped talking to me entirely when we were in front of patients. He stopped teaching me. At what would become our last meeting together, he refused to acknowledge my concerns about a clinical issue. It seemed like he was trying to pick a fight with me. We fell silent. He looked at me with amusement. I glared at him.

“Are we done?” I still felt like I needed his permission to leave.

“Yup!” He grinned. It was clear I had to talk with my residency director.

She believed me. She was swift and immediately pulled me from the rotation.

One of my fellow trainees, a robust man who played football in college, was assigned to work with him for the following six months.

My fellow colleague believed me. He was swift. He objected and asked for another rotation, stating that he didn’t feel comfortable working with a physician who had mistreated another trainee.

The psychiatrist ultimately left the institution, following an administrative leave.

Sexual harassment occurs in every profession, even medicine. To stop this, we need as many people as possible — men, women, colleagues, advisers and leaders — to support women and act swiftly when these events occur. I was fortunate, but not all women are.

Categories
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.