Category: Systems

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Observations Reflection Systems

Race.

No one was sitting near us at the fast food chain, but my dad lowered his voice anyway.

“You were three or four years old,” he said. “We were watching an NBA game on TV. You asked, ‘Where are the white people who play?’ Even little kids notice these things.”

“How did you answer my question?”

“I didn’t.”

About 5% of inmates in the jail are in psychiatric housing at any given time. My current post assignment is with males who demonstrate acute symptoms, which comprises about 2% of the entire jail population. A small team works with this 2%.

To be clear, not all people with psychiatric conditions are put in psychiatric housing. Sometimes people start there and, as their condition improves, they move on to general population housing. Some people with psychiatric conditions never come to psychiatric housing. How one behaves, not one’s diagnosis, determines where one is housed.

I don’t know if the racial mix of my patients is proportional to the racial mix of all the people in jail. It’s rare that the patients I care for are comprised of only one race. I have yet to ask, “Where are all the white people?” However, I’ve certainly asked that before in another correctional setting.

I’ve often framed the processes of clinical work as a game. Maybe this is a product of clinical training: When working in hospital services, you’ve “won the game” if you were able to discharge all of your patients. You make informal wagers as to the duration of rounding: “Oh, our attending is Dr. So-and-So, so we’ll finish in less than an hour, tops,” or “Dr. Blah-Blah is on service now. You think three hours? Four? Five?!”

It’s probably just one way of coping.

While on various outreach teams, the objective of the game was to keep all of my patients out of the hospital. When working in a clinic in a medical center, it was to get all my patients well enough so that I could send them back to primary care. Now, the game is to get them out of the most acute unit and prevent them from returning. (The object of the game really should be how to keep people out of jail. That requires coordinated efforts across space and time, particularly for people with complex psychiatric conditions.)

Sometimes my patients are young black males. Sometimes they talk about problems they’ve had with officers or other inmates in the jail.

“I don’t want you to come right back to this unit if we send you out.” That’s how I usually start it. “If someone else gives you a hard time or starts being a jerk to you, what are you going to do to help you stay there and not get sent back here?”

People are often doing much better by the time we’re able to have this conversation. They usually provide reasonable answers.

Even though no one else is sitting near us, I then lower my voice.

“You’re a young black man. Some people here—not everyone, but some of them—react to you in certain ways just because of the color of your skin. That’s not fair, but, sometimes, that’s what happens. You know this much better than I do.”

I remain struck with how their faces soften. Jail is a hard place to be and people adopt hard expressions on their faces. When this coversation happens, these young black men invariably smile, but not from joy.

“So if something happens, you have to figure out how to respond so that you’re not the one who comes back here. Does that make sense?”

Sometimes they thank me for talking about race; sometimes they tell me that they already know what they need to do; sometimes they simply assert, “Don’t worry, I won’t come back here.”

Why do I lower my voice when I talk about this? Would I bring this up if I were a white female? a white male? Does the fact that I look obviously Asian work in my favor? Do I need to bring up something that they already know? Am I just being rude? Do good intentions matter when people find the intentions condescending?

Am I actually helping them when I frame things this way? Or am I only making myself feel better?

It’s a small sample size and completely anecdotal: After we have this conversation, they don’t return to the unit.

Maybe they were never going to come back, anyway.

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Consult-Liaison Education Medicine Nonfiction Reflection Systems

Reflections While Writing About Psychiatry

I know I haven’t posted in a while. Someone presented me with the opportunity to write a section on psychiatry for medical students. This is wonderful (an opportunity to influence future physicians!!!) and terrible (GAAAAH there’s so much in psychiatry!!!). Between thinking about psychiatry at multiple levels at work and thinking about the foundations of psychiatry while writing the section, I’ve felt cognitively impaired when thinking about what I should write here.

But the thinking never stops… and here are some reflections I’ve had over the past two months while writing:

The differences between what physicians and patients want. Many medical students choose medicine because of the opportunity to help people in a very real way: In helping people improve their health, physicians help people experience a better quality of life. This is rewarding for both patient and physician. Right?

As physicians go through training, they learn the heartbreaking lesson, often repeatedly, that it’s not that simple.

Sometimes people want physicians to help them in ways that physicians can’t or won’t. Some people want medicine that will make the cancer go away and never come back. Other people want pain medicine or sedatives for short-term relief, though the long-term consequences are problematic and potentially devastating.

Other times, people reject the best help that physicians offer. Some people will not take insulin, even though it will prevent prevent worse outcomes from diabetes. Other people don’t want to see any physicians, even though medical interventions for their conditions are simple and effective.

Many medical students assume that patients will only be grateful for and accepting of the help physicians offer. That assumption is wrong.

But this is part of the “art” of medicine, right? How do physicians and other medical professionals help people when we don’t have an intervention that “works”? How do we help people who don’t want the help that we know “works”?[1. There are, of course, strategies we learn as psychiatrists to address how to help people who don’t want the help physicians offer. The problem is that the issue then gets cast as a “psychiatric problem”, when it, in fact, is a “human relations problem”. Psychiatrists often feel frustrated when some physicians either want us to have the doctor-patient relationship in their stead or, worse, when some physicians assume that a Disagreeing Patient is a Mentally Ill Patient.]

The psychiatric conditions that psychiatrists don’t encounter. I’ve worked in a variety of settings—in clinics, hospitals, a crisis center, a jail, homeless shelters, housing, and on the street—and, despite all that exposure, I have never met with someone with a diagnosis of somatic symptom disorder or factitious disorder. While both conditions are rare, my colleagues in primary care and emergency departments see people with these conditions more frequently. Those same people don’t want to see a psychiatrist.

When we think about systems that take care of patients, sometimes we need to remember that the patient isn’t always the actual patient. Sometimes the best way psychiatrists can help these patients is to help the physicians who actually see them. If we wipe our hands and say, “Well, they won’t see me, so that’s not my problem,” what are we doing? If there are barriers in the system that prevent us from helping our colleagues, how can we work together to remove them to increase the likelihood we can help them?[2. This is an argument for “integrated care”, which refers to the integration of physical and behavioral health services. Unfortunately, how these services are paid for often creates barriers… which is exactly why we need more physicians involved in advocacy and leadership.]

Conversations on what is “wrong” instead of the experience of being ill. While in training, physicians learn how to diagnose and treat conditions based on what is “wrong”. We learn the characteristics of the condition, its underlying causes, and the treatments that often correct it. However, we don’t spend a lot of time learning just how much the condition afflicts people.

To be fair, there is so much to learn in medical school and beyond. Furthermore, physicians, as a population, like to solve problems. This temperament was likely present in all of us even before we went to medical school. If talking and listening won’t actually fix the problem, but doing Something actually will, why don’t we just do the Something and get on with it?

Because of this focus on Fixing the Problem, some people assume we are uncaring. That assumption is often wrong, too.

There are also other forces at work: Physicians often don’t have as much time with patients as they would like to listen, provide education, and offer encouragement. Those are Receptive skills and, while complementary to, are often not as glamorous (or billable) as Problem-Solving skills. All of us—in health care or otherwise—often forget that healing occurs with both Receptive and Problem-Solving skills.

I’m grateful for many reasons to have this opportunity to write for medical students. A major reason is the chance to explicitly go back to the basics. Examining the foundation reminds me why I chose to go into psychiatry in the first place, highlights (again) just how much I don’t know, and challenges me to consider what is actually important in my clinical work. And let me tell you, knowing the doses of various medications is not actually important. That’s stuff you can look up. As Dr. Edward Trudeau said, what is actually important is “to comfort always”.[3. The full aphorism attributed to Dr. Trudeau is “To cure sometimes, to relieve often, to comfort always.”]

Categories
Education Medicine Nonfiction Observations Systems

A Day in Jail.

Three of us are waiting for the elevator. A few moments earlier I had walked into the jail for the day, so I have not yet donned a white coat. The other two are wearing their standard uniforms: The inmate is in red and the officer is in black.

“I have to take my seizure medicine while I’m here, you remember, right?” the inmate says, clutching a clear bag holding several pill bottles, a pair of jeans, and a dark jacket.

“Yes,” the officer says, her voice warm and firm at the same time. “You told the nurse, right?”

“I always do, ma’am.” A shy smile crosses his face. She smiles back at him as the elevator doors open. She motions for him to enter first.

The hem of the white coat hits the back of my calves as I climb the stairs. My habits from my intern year remain: I still fold papers in half lengthwise and the first stack will go into the left pocket. I never button my coat.

When I reach the top of the staircase, one of the standing inmates glances at me, then returns his gaze to the inmate seated in front of him. The standing inmate looks like he’s in his 20s. The seated inmate might be in his late 30s. Twenty-something guides the electric razor along the contour of Thirty-something’s head; clumps of light brown hair tumble onto the black cape and the concrete floor.

There are two barbers on duty. They volunteered their services; they will probably get extra food as compensation. The men in the chairs bow their heads, their eyes open, their bodies still. No one says anything.

Everyone gets the same haircut.

The floor officer is worried about an inmate: “He didn’t eat breakfast this morning and wouldn’t come out to take a shower.” While I scribble this information down on my paper folded lengthwise, I hear the deck officer raise his voice.

“What are you looking at?” the deck officer barks at two inmates. They are trustees, which means that they have demonstrated good behavior while in jail and are allowed to participate in chores. In exchange for doing tasks such as preparing meals and cleaning floors (which also gets them out of their units), they can receive more food .

A trustee mumbles something in response.

“I asked you, what are you looking at?” the deck officer barks again.

“Nothing, sir.”

“Okay. If I see you looking at ‘nothing’ again, I’m sending you back. Do you understand me?”

“Yes, sir.”

“Get back to work.”

The floor officer and I ask the deck officer what happened.

“They saw you,” he says, pointing at me, “and started grinning, elbowing each other, all that stuff.”

While wrapping my coat tighter around me, I glance at the two trustees. One of them happens to look at me at the same time; he turns away and takes a sudden interest in the mop in his hands.

“Thank you, Officer.”

“Just looking out for the doctor.”

It’s been a few years since I’ve talked to God.

Perhaps I meet God more frequently, but s/he chooses not to reveal that to me. More often I talk to angels or the Anti-Christ.

“Psychiatry is sorcery,” God tells me. “If you only had more faith, you would see the error in your ways. Turn towards faith and away from your analytical ways of thinking.”

God is charged with criminal trespass. God is a young man. His bail amount isn’t that high. Is there no one in God’s life who could post his bail so he could get out?

“One of the best things about being God,” he tells me, “is that I can see the true intentions of people. I know their thoughts.”

He pauses and looks at me.

“Although you practice witchcraft, I can tell that you’ve got a good heart. I will pray for you that you will have more faith, that you will believe in me.”

I will pray for you, too.

When I’m finished talking with God, the floor officer comes by and gives God a second lunch.

“Thank you! I bless you!” he calls out.

The brown paper sack contains one sandwich (two slices of wheat bread, one slice of bologna), one mayonnaise packet, one slice of American cheese wrapped in plastic, a small baggie of baby carrot sticks, and one apple the size of a tennis ball.

“He’s still growing,” the floor officer murmurs.

The day has ended. I’ve already stuffed my white coat into a laundry bag, but I’m still making my way through all the doors to physically get out of jail. When I exit the elevators near where inmates are booked into jail, I see an officer wincing and grasping his leg. One medic is kneeling by him; the other is on the phone.

I pass by a bank of holding cells. Two women knock on the wall and beckon me towards them. The one with tattoos all over her young face and anxiety in her eyes asks, “Can you tell them to let us out? We’ve been waiting a long time.”

“An officer looks hurt,” I say, raising my voice. We’re talking through a thick pane of plexiglass. “The medics are here. It might be a while before they will get to you.”

“Oh,” she says. They take a step back and their shoulders slump. “I hope they’re okay. Thanks.”

Most people look either relieved or thrilled when they leave jail. They throw their shoulders back as they cross the threshold from the jail lobby into the fresh air. How much more comfortable they appear in their own clothes! The red uniforms incarcerated them just as much as the concrete block. Sometimes they give each other high fives; their voices are light and bright as they tell each other to take it easy.

A few will look up and around, confused and forlorn. They squint at the numbers at the bus stop. After taking a few steps heading south, they pause, turn around, and head north. They finally decide to cross the street to get away from the jail. It seems like the best idea.

Categories
Education Medicine Policy Systems

Inspiration from the Surgeon General.

Somehow people knew he was about to enter the room. The thirty or so people in the room were seated, though people began to stand up.

“Are we supposed to stand up for the Surgeon General?” I asked the person sitting next to me.

She shrugged. If we remained seated, everyone would have noticed. So we stood up.

“I’ve been in this position for a year and a half,” Dr. Murthy said, “and I’m still not used to people standing up for me. Please sit down.”[1. I learned later that the Surgeon General has the rank of a Vice Admiral, as the role oversees uniformed health officers. That’s why people stand up for the Surgeon General.]

We were all in that room for about an hour, but Dr. Murthy said little. After some opening remarks about the Turn the Tide initiative related to the opioid epidemic, he asked the audience to tell him what was going well and what could use improvement.

I had never met him before, but I was immediately struck with his listening skills. It was as if he was taking a history from a multi-person patient. He made and held eye contact. He didn’t fidget. He spoke in a quiet yet firm voice. Though he didn’t come across as warm, it was clear that he was interested in and paying attention to whoever was talking to him. His thoughtful follow-up questions indicated that he was listening to what people were saying to him.

He seemed like a good doctor.

As I had never met a federal official before, I later learned that Dr. Murthy was also unusual in that he took notes. (Fun fact: He’s left handed.)

“These are usually publicity events without a lot of substance,” a more seasoned co-worker commented.

By the time the meeting was over, he had covered a sheet from a yellow notepad with copious notes. He expressed what seemed like genuine thanks to us for our time and perspectives.

It was through luck only that I was there. A colleague told me a few days prior that the Surgeon General was scheduled to speak to a local task force related to the opioid epidemic.

“The Surgeon General?” I blurted. “I’d love to hear what he has to say.”

“Then you should come.”

“What?”

Afterwards, as the Surgeon General’s staff were trying to hustle him out the door, the same colleague who invited me to this event gave me A Look. Only I could see the thought bubble above his head: “Go ask him for a photo!”

Though I appreciated Dr. Murthy’s humility, thoughtfulness, and professionalism, I was also grateful and amused with his willingness to stop for a photo.

Earlier that day I was seeing patients.

“Do you know how much longer you’re going to be jail?” I asked.

“Ten or eleven days.” He looked at my left hand. “You’re married?”

“Yes.”

“I should start going to NA meetings again. I’m never gonna meet a woman in here and I get so depressed about not having a family. I want a wife and kids, like my brother. I don’t know why he got so lucky and I got screwed. The TV doesn’t talk to him, he’s got a wife and three kids, God blesses him, but I will wait because the meek shall inherit the earth—”

“What do you think will help you not pick up when you get out?”

He shrugged. “I still don’t have a place to live. Dope helps me feel better.”

We looked at each other and said nothing.

The reality is that the Surgeon General (or any other public official) is just one person. Though he has a grand title, he alone cannot make improve health care. He is part of a system. We can only hope that he and his office will be able to shift the system—even if only just a bit—so that it works better to serve the US population.

What the Surgeon General can do and, at least for me, has done, is inspire physicians to get involved and do better. He could have swept into the meeting and spoke at length about his accomplishments and his status within the federal government. He instead presented himself as a humble ambassador and servant. He demonstrated interest in what our locality has witnessed and experienced. He recognized that, even though he was an academic physician, he is now too far removed from clinical care to speak first as an expert. He solicited and accepted feedback, some of which was discouraging. He was professional. He wasn’t defensive. He acknowledged that it may seem like our feedback would disappear into a void in Washington, DC, though everything else he was actually doing during the meeting gave us hope otherwise. It’s quiet leadership.

There are a lot of problems with health care. Physicians and patients both know this. Physicians are trained to take care of people, not to create and manage financial systems that should only support the relationships between physicians and people. However, if physicians are not involved in the conversations about these systems, then we are not advocating for the patients we serve and the profession that gives us the privilege of doing so. Yes, I know we’re too busy taking care of patients to participate in these conversations that can seem bloated and irrelevant. However, if we don’t get involved to define the problems and solutions, how could we ever expect these systems to improve?

Categories
Observations Reflection Systems

Black Lives are Also Lives.

For the past few weeks I have felt discouraged about ongoing local, national, and global violence. I felt powerless to do anything—including write—to help make things better. I could not find the words to express my sorrow.

So I turned to Buzzfeed.

I came across an article describing the efforts of Asian-Americans who were writing letters in their respective Asian languages to their parents about Black Lives Matter. My father and I hadn’t discussed the deaths of Philando Castile and Alton Sterling. However, the topic of race in America comes up in our conversations every few months.

Several months earlier, while discussing experiences of racism in his life, my father commented, “The Chinese should not be surprised to experience racism. We made the choice to come to America. It was voluntary. Black people didn’t have a choice. They were forced to come here.”

It was a perspective that I hadn’t considered before. And while I understood his point, I wondered what degree of racism any person should experience without feeling “surprise”.

It was only recently that I understood that some people who hear “Black Lives Matter” interpret that to mean “Only Black Lives Matter”. Thus, the rebuttal “All Lives Matter” came into being.

Of course All Lives Matter, I thought. That’s the whole point. Perhaps it would be more precise to say Black Lives Matter, Too.

I asked my dad if Black Lives Matter was receiving as much media attention in Taiwan and China as it was here in the US. I also expressed my surprise about the rebuttal of “All Lives Matter”.

“The Chinese media talk about it in a different way,” he said. “It’s not ‘Black Lives Matter’. It’s ‘Black Lives are Also Lives.’ It’s more clear.”

Indeed! There is no pithy retort to that. The clear implication is that we, as a society, value lives. The death of a Black life should disturb us as much as the death of any other life.

For all of us who are ever considered The Other—and everyone, at some point, is considered The Other—we must support the other Others.[1. We support other Others if their causes are noble and just. Make no mistake: I am not saying that we should support The Others who advocate for genocide, torture, etc.] There was a time in the US when The Majority were fearful of the Chinese, which resulted in the Chinese Exclusion Act. This was the first law that explicitly stated that a specific ethnic group could not immigrate to the United States. Though this law was ultimately overturned in 1943 (not even 100 years ago!), the Chinese are still the only ethic group specifically named for exclusion in the United States Code.

People who were not of Chinese descent disagreed with this law before, during, and after its implementation. They also supported its repeal.[2. I understand that some people opposed the Chinese Exclusion Act solely for commercial reasons. They did not care about equality. I’m not talking about those people.] I am grateful that they spoke up. Had they not, my parents would not have been able to immigrate to the US, contribute to this society, enjoy what America has to offer, and raise a daughter who now writes this blog.

We all speak up in our own ways: Some people participate in protests; others write words for others to read; still others have quiet conversations about it. Advocacy takes many forms. Choose what works best for you.