Category: Systems

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Medicine Observations Policy Reflection Systems

On “Mental Illness”.

I’ve been invited to speak to a group of attorneys who work at the interface of psychiatry and the law. The topic of my talk? “Psychiatry 101.”

A psychiatrist who gave this talk to a similar group a few years ago advised me: “You should assume that lawyers are laymen. It’s surprising how little they know, given the work that they do.”

This teaching opportunity to teach has given me pause: What is mental illness?

Most of my work has been with people with few resources (no home, no job, etc.) or with people who are experiencing symptoms that cause significant distress (they won’t eat because they think all food is composed of their internal organs; they often try to kill themselves due to hearing voices telling them to do so; etc.). Most people would agree that these individuals have “mental illnesses”, whether “caused” by their circumstances (imagine people trying to set you on fire or rape you because you are sleeping outside) or by apparent biological events (imagine a freshman in college with an unremarkable history who, over the course of months, begins to believe that the government inserted a chip into his brain).

I have also worked in settings where:

  • a wealthy man’s wife felt overwhelmed with anxiety about which of their three homes they should remodel first
  • a aerospace engineer with no symptoms wanted to try an antidepressant because his girlfriend started taking one and she now seemed to have greater clarity of mind; “maybe that will happen to me, too”
  • a college student felt depressed because his parents wanted him to pursue a professional degree, but he didn’t want to do that

Do those individuals have mental illnesses? Does psychological suffering equate to mental illness? Even if they are able to get on with the necessary details and difficulties of life?[1. Do not misunderstand: People with means can and do have mental illnesses. Take the software developer who was certain that public surfaces were contaminated with exotic diseases; he couldn’t get himself to go to work or spend time with friends due to fears that he would get sick and die. Or the accountant who, if she doesn’t sleep enough, would believe that she is the mother of God; she went to hospitals insisting that she was in labor with Jesus when, in fact, she was not pregnant.]

My mind then spins to recent events, such as the Germanwings place crash. Many people have argued that, because the co-pilot killed people, he was mentally ill. He apparently had a diagnosis of depression, but I agree with Dr. Anne Skomorowsky that a diagnosis of depression alone does not explain why he committed mass murder.

But if he was mentally ill, what diagnosis would best describe his condition? What do we call it when people kill other people? Is that behavior alone sufficient to say that someone is mentally ill? If so, what do we make of:

  • soldiers killing other people during war
  • gang members who, without provocation, shoot police officers or other gang members
  • suicide bombers
  • parents who kill their newborn infants because the babies aren’t the parents’ desired sex

Does a person’s intentions affect the definition of “mental illness”? (How good are we at reading the minds of others? We often assume intention when observing behavior. And those assumptions can be way off.) Does the situational context also affect what a “mental illness” is? (When in Rome, do you do as the Romans do? What if you don’t know what Romans do?)

People have surmised that people who kill other people may have conditions such as antisocial or narcissistic personality disorder. However, these designations are still problematic: Not everyone with those personality disorders kill people.

Perhaps this is why I prefer to work with people who demonstrate behaviors that undoubtedly impair their function.[2. It is easier for me to work with people who demonstrate clear evidence of “impairment in function”. Part of this is due to the greater ease and clarity in diagnosis: If someone’s symptoms are within the spectrum of normal human experience, then diagnosis is unnecessary. Part of this is also due to treatment: Some interventions in psychiatry—specifically medications—are not benign. Furthermore, it is unclear how some—many?—psychotropic medications work. We first must do no harm.] I am reluctant to describe most people as “mentally ill” because some behaviors that people find bizarre have helped the person cope with their circumstances. The people who always wear masks or scream on the street? Those behaviors may have somehow protected them in the past—even if it means that the general public derides them for being “weird”. It seems unfair to say someone is “ill” when what they have done before in the past has given them some degree of protection. (To be clear, I don’t necessarily apply this formulation to people who have committed murder. For example, I can’t think of how flying a plane into a mountain could ever be an adaptive coping skill.)

Words matter. I’m not sure that I have more clarity yet about what I should teach, though it is clear that I should focus on how I phrase the information I present.

Categories
Education Funding Homelessness Observations Policy Systems

Asylums are not the Answer.

The New York Times recently featured an op-ed from a psychiatrist, Dr. Montross, who argues for the return of the asylum.

I understand her frustrations: I have worked with homeless individuals in both New York and Seattle who, if they were in psychiatric institutions, would not have had to worry as much about their safety, getting food, or sleeping at night. Many of the patients I now see in jail should undoubtedly be in a psychiatric institution (though not necessarily for a long period of time).

However, I disagree with her assertion that we should return to the era of the asylum.

President Kennedy signed the Community Mental Health Act into law in 1963. The goal of this legislation was to move people out of long-term psychiatric institutions, such as state hospitals, and help them integrate into the community by enrolling them in outpatient services. This is what “deinstitutionalization” refers to.

The Community Mental Health Act, however, only provided funds for the construction of the community mental health centers. The law made no provisions to fund the services that would occur in these buildings.

What we see now—the “transinstitutionalization” of people with severe psychiatric conditions into homelessness and jails—is a consequence of this lack of funding and support for patient care services.

Think of it this way: A city wants to improve its public transportation system. The city passes a law that provides funds to buy a lot of buses. However, the law provides no money to hire and retain bus drivers. There is also no money to hire and retain mechanics for bus maintenance.

The people of the city are frustrated: “Our public transportation system sucks! The city should build a subway system!”

The bus system never got a fair chance.

We also moved away from asylum care for good reasons: Conditions in psychiatric institutions were often terrible. It was not uncommon for state psychiatric hospitals to have insufficient staff for the number of patients in the institution. In Alabama in 1970, one psychiatric institution had one physician for every 350 patients, one nurse for every 250 patients and one psychiatrist for every 1,700 patients.

Dr. Montross herself notes (emphases mine):

But as a result, my patients with chronic psychotic illnesses cycle between emergency hospitalizations and inadequate outpatient care. They are treated by community mental health centers whose overburdened psychiatrists may see even the sickest patients for only 20 minutes every three months.[2. Unfortunately, 20-minute appointments every three months for the sickest patients is also a common occurrence here in Washington.]

If that is the quality and quantity of care “the sickest patients” in outpatient settings receive, then of course “many patients struggle with homelessness” and “many are incarcerated.”

Dr. Montross calls for “modern” asylums, though it is unclear to me what incentives government has at this time to build and support institutions that “would be nothing like the one in ‘One Flew Over the Cuckoo’s Nest'”. Asylums from years past did not receive sufficient funding to provide adequate care. Current outpatient centers often do not receive enough funding to provide adequate care. (How much longer must we wait before this changes?)

To be clear, I do believe there is a role for asylums in patient care. There is a small segment of the population with severe symptoms who would benefit from care in an institution. I’m talking about people who keep trying to jump off of buildings because they believe they can fly. Or people who cannot stop smashing their heads against the wall because they are trying to dislodge the computer chip they believe is in their heads. Or the people who eat their own feces and literally cannot use words to explain why.[1. As I have noted before: If you do not believe that these scenarios actually happen, I encourage you to volunteer at your local emergency department.] These individuals can and do recover; they are not necessarily destined to spend the rest of their lives in an asylum.

We also now have interventions such as assertive community treatment, assisted outpatient treatment[3. Assisted outpatient treatment is controversial, though preliminary data support its use. You can read an admittedly biased summary about it here.], and supportive housing/housing first. There is evidence that these intensive outpatient services keep people in the community and out of psychiatric institutions. What would happen if government and communities supported these interventions?

Modern psychiatric services—in an asylum or elsewhere—will not be modern at all if there are not enough staff to provide care for patients. It also will not be modern if the staff do not receive ongoing training and supervision for the care they provide. It cannot be modern if administrators do not understand the work and are unwilling to provide financial, technical, and emotional support to the front-line staff.

We must get away from the idea that where people receive services is more important than the quality of those services.

Categories
Education Medicine Systems

Negotiating a Job Offer (II).

The second thing to ask for when negotiating a job offer is a table of organization. Like the job description, if you are able to review this during your interview, do so. That will give you the opportunity to ask clarifying (not negotiating) questions during the interview.

A table of organization is a sheet of paper with boxes and lines on it that tells you who reports to who. It shows the official hierarchy of the organization. Your position should be on the table; there should also be a line from your position that leads up to your direct supervisor. It should also indicate who reports to you. Many organizations will not share this information with you before you are hired unless you ask for it. Some organizations don’t share this information with you even after you are hired.

If you have Machiavellian ambition, the table of organization also provides a roadmap as to how you can get to the top.

But even if you are not a fan of Machiavelli, the table of organization gives you useful information. Say you want clinical consultation related to the practice of medicine. Your supervisor, however, has the letters “MBA”, “LICSW”, or “JD” after their names. You thus can expect limited assistance from them. Maybe your supervisor is a physician, but is in a different specialty. Clinical consultation may not be useful there, either. Find out before you start a job who will provide clinical supervision for you.[1. If you don’t have an official clinical supervisor, make a point of finding out where you can get help for clinical matters because we all need it sometimes.]

If you have questions or concerns about issues related to the system of care, it’s useful to know if your supervisor can help. It’s also useful to find out who your supervisor reports to (and so on up the chain) because that will affect what information you have access to, how you are treated, etc. For example, as a staff physician, the table of organization might show that you eventually report to the Chief Medical Officer, who might then report to the Chief Executive Officer. However, it is also not unheard of for staff physicians to report to a medical director, who then reports to a director of clinical services (who may not be a physician), who then reports to a deputy director, and then an executive director. If the director of clinical services doesn’t like doctors, or the medical director doesn’t advocate for the medical staff, then your requests might not get the attention they deserve.

You might also find yourself reporting to more than one person. Depending on who they are, that could be fine… or you might feel like a kid with bickering parents.

The table of organization will also tell you who you supervise (if anyone at all). Maybe you don’t want the responsibility of having subordinates. Maybe you do. Maybe you want that possibility in the future, but not now. And maybe the table shows people reporting to you that you are not qualified to supervise. For example, you might have a cadre of nurses reporting to you. There is overlap in the knowledge that physicians and nurses use in their work, but most physicians do not have the skills or expertise to provide satisfactory clinical supervision to nurses.[2. Just because you have the letters “MD” after your name does not mean that you are qualified to supervise everyone, just as someone with the letters “MHA” after their name doesn’t mean that they are qualified to supervise you.]

Do also note that the table of organization you receive from your employer is the “formal” table of organization. There exists in every organization an “informal” table of organization. You usually learn about the “informal” table through word of mouth. Maybe people are supposed to report to a specific individual, but they actually talk to someone else on the other side of the table for help and information. That’s not information you might get during the interview process, but if you have inside connections or opportunities to talk with current employees, you can ask.

For example, maybe the official supervisor doesn’t actually provide useful supervision and you’re better off talking to another staff physician. Or maybe the medical director isn’t assertive, so if people want the Vice President of Clinical Affairs to know something, they cultivate some sort of relationship with that VP or someone along that chain.

This sounds like “politics”. Where there are people, there are often politics. You, however, want to be prepared: When problems come up—and they will—you want to know who you can and should talk to.

Next post: Stuff you can negotiate for.

Categories
Education Lessons Medicine Systems

Negotiating a Job Offer (I).

The first thing you should ask for—if you haven’t already received it—when negotiating a job offer is a job description. This is a document that often has bullet points that describes the title and duties of the job, required and preferred qualifications of the applicant, and basic (and sometimes vague) information about salary and benefits.

Sometimes employers post the entire job description as a classified ad. Sometimes they post an ad that is a three-sentence summary of the job description. Sometimes they send out an e-mail that announces a job opening. Sometimes you hear about a job from a friend and you’re invited to sit for an interview when you call the employer to express interest.

The point is that you could end up sitting for a job interview without ever seeing a formal job description. If you can get a job description before or during the interview, get it: You can ask clarifying (not negotiating) questions during the interview.

It sounds obvious, but the value of the job description is that it tells you what your employer wants you to do. You learn what is expected of you and what you can expect in return.

Maybe you prefer hospital work to clinic work. The job description should tell you if you have to do any clinic duties, such as providing coverage when people are on vacation. If you will be conducting research, teaching, or doing administrative stuff, the job description should tell you how much time and other resources you will have to do that work.

Without a written job description your employer could shift or change your job duties in what seems like a unilateral fashion:

“But when I interviewed, you told me that I would never have to cover the inpatient consult service.”

“Well, that’s where we need coverage right now. Starting next month, we’d like you to do that two days a week.”

Thus, the job description also provides the basis for job negotiations. Review the job description to see if anything is missing (like specific job duties, particularly things you like to do) or if there are details that you want changed (perhaps you want more leadership responsibilities that merit a higher salary).

The job description can provide the foundation for a job contract (or a “hire letter”, as some agencies don’t use contracts). Not every detail about your job has to be in writing. For those details you care about, though, written descriptions of your role and responsibilities make expectations clear to both you and your employer.

Sometimes employers—such as small agencies or new, innovative programs—don’t have job descriptions. Maybe the job description is vague (“will provide clinical services”). What should you do then?

You’ll have to look for other cues during the interview and recruitment process to discern how much to push for a job description. In some cases it is clear that a job description won’t be useful. Consider a start-up project, where no one can anticipate what the program will eventually look like or how your role will evolve over time. Maybe the organization only has ten people and things are routinely discussed and resolved informally. To be clear: If the employer doesn’t give you a job description, that doesn’t automatically mean that the employer is going to screw you over. It just means that they don’t have a job description to give you. It also suggests that you have the opportunity and flexibility to tailor the job to your specific interests and strengths.

Given the often rigid structure of medicine and that physicians are trained to do specific things, we may not think that a job description can help us (“I’m going to work as a doctor”). Asking for a job description, though, can help you shape your job so that your work life is as fulfilling as possible.

Next post: The second thing you should ask for.

Categories
Education Informal-curriculum Lessons Medicine Systems

Negotiating a Job Offer (introduction).

I recently gave a talk to psychiatry residents about how to negotiate a job offer.[1. The focus on the talk was on negotiating a job within an organization that is already established—a “typical” job for a physician. There is more flexibility—and uncertainty—for start-ups and other innovative programs that deviate from standard models of medical practice. For those of you who are trying/creating something new and different, good for you: We need you.] Our resident cohort did not receive any formal instruction about this[2. When I was a resident a few attendings in private practice did talk with us about how to hang up our own shingles. Most of the people in my cohort did not go into private practice.] and I don’t know if this is a topic that is common in resident education. It seems that physicians, as a population, aren’t skilled in negotiating job offers.[3. I wonder if physicians don’t think or learn about job negotiation because of our training experiences: To get into medical school we learn to jump through various hoops that others set aflame; we learn how to sit through interviews, though we’re rarely in a position to ask for what we want; we cannot negotiate where we go for residency; we are usually unable to negotiate the finer points of our clinical rotations; and, by the time we complete our residency training, we’re relieved to have more freedom and salary than we did as trainees, so we don’t ask for anything more.]

My suggestions for negotiating a job offer may not be comprehensive, though I hope that they will help new graduates and “early career” physicians have more confidence and skills when talking with potential employers.

I’ll write about two items of information candidates should always ask employers for. Most candidates don’t ask for these two items, though they can clarify the job, set expectations for both employer and employee in the future, and provide ideas for negotiations.

I’ll also share a list of negotiating items that are particularly relevant for physicians. Given that each specialty in medicine has its own practices and culture, consider the list a starting point.

Lastly, I’ll suggest general attitudes and perspectives that candidates (particularly women) can hold during the negotiation process to make it less daunting. Expect some cheerleading.

A caveat to begin: Do not start negotiating until a job has been offered to you. Even though you might burst with excitement about the job and believe that you are well suited for the work, the employer may not share your sentiments. Negotiating details of a job before it is yours is foolish. Imagine if the tables were turned: You’re sitting in an interview and you don’t want the job. Meanwhile, the employer is saying things like, “So… could you work every Thanksgiving, Christmas, and New Year’s?”

The interview process is your opportunity to ask questions, watch how the employer is behaving (because the people talking with you should be on their best behavior), and learn if you, the work, and the employer are a good enough fit. Though the employer initially has more power (as they are offering you a job, not vice versa), that doesn’t mean you are powerless: All the things you learn during the interview will help you decide whether you will accept their offer. And maybe there are some things you’d like to be a little bit different before you agree to work with them. That’s what negotiating is about.

Next post: The first of two things you should ask for during the interview.