Category: Systems

Categories
Medicine Observations Systems

Representation Matters.

This post comes directly from a Twitter conversation I was in a few days ago:

Screen Shot 2018-04-22 at 1.28.25 PM

… though this topic has actually been on my mind for nearly a year due to some events that have occurred at work.

Many medications that were originally developed for the treatment of schizophrenia, called antipsychotic medications, are now used for other conditions, such as major depression and bipolar disorder. (The reasons for this are beyond the scope of this post. However, I will comment that this is why the “serotonin theory” of depression should really be called the “serotonin hypothesis“.) Several antipsychotic medications come not only in pill form, but are also available in long-acting injectable forms. Instead of swallowing pills everyday, some people receive an injection of medication once every few weeks or once a month. These medications are injected into shoulder or butt muscle.

Some people prefer to receive injections because that means that they don’t to remember to take pills everyday. Many people who accept long-acting injectable medications do well. No one would guess that they have had experiences hearing voices or believing fixed, false ideas. Some of these individuals report that these medications have saved their lives.

Some people, in varying degrees, are coerced into receiving injections (e.g., payee allowances—money—are handed over only after the individual receives the injectable medication; courts “encourage” individuals to receive injectable medication). Long-acting injectable medications are never used in emergencies, regardless of who is defining the word “emergency”.

Most people prefer not to get shots of medication, even if they know they are in their best interests. Many adults look away and wince when they receive vaccines, even though they know that the benefits far outweigh the risks. Most vaccines, though, are available only in injection form, so people don’t have a choice as to how else they can receive the vaccine.

So, with that, let’s look at the advertisements for long-acting injectable antipsychotic medications and any intersections they have with race. The target population is admittedly small: Only around 1% of the population has a diagnosis of schizophrenia at any given time. (However, if you’re part of that 1%, this stuff matters a lot.)

Here’s the landing page for one long-acting injectable antipsychotic medication:

InvegaSust

We see what look to be white people with sporting equipment. I’ve drawn in a pink arrow to show the link that leads to the page about the use of this medication for the treatment of SCHIZOPHRENIA. If you click on that link, it brings you here:

InvegaSchizophrenia

Anything different about the people in the photo?

There are journal articles that span decades that show that schizophrenia is overdiagnosed in black people. One wonders: Do the ads come from the overdiagnosis? Or does the overdiagnosis come from the ads?

To be fair, if you scroll through the photos in that image, the other photos are of white people, including women. However, the scrolling does not automatically occur. The photo of the three men of color is what you see when you click on “schizophrenia” from the main page.

So what happens if you click on “schizoaffective disorder” from the page for schizophrenia? (Curious that there isn’t a link to schizoaffective disorder on the main page.) This shows up:

InvegaSchizoaffective

Only women for a psychotic disorder that also features mood symptoms, huh? (Side note: There’s ongoing debate within psychiatry whether schizoaffective disorder is even a valid condition. Meaning, psychiatric researchers are still arguing about whether this condition even exists. This is a topic for another post.)

“Oh, Maria,” you might be thinking. “You’re reading too much into this. It’s just one ad for one medication.”

Okay, let’s look at another long-acting injectable antipsychotic medication. How about this landing page?

AbilifyMaintena

Note the comment in the bottom right-hand corner: “Model portrayals.” Meaning, the company chose these specific images for these specific diagnoses.

The “schizophrenia” link takes you to a page that has scrollable photos: Two women with less melanin and a man with more melanin. The “bipolar” link has two scrollable photos: One light-skinned woman and a darker-skinned man. Maybe there’s something there; maybe there’s not.

Here’s another one for essentially the same medication, but with a different manufacturer:

Aristada

Okay, so this photo assortment seems to strike a more even racial balance. I won’t nitpick further on this one.

Let’s go to the longest-acting injectable antipsychotic medication on the market right now, an injection that is administered once every three months:

Trinza

Oh goodness.

If you click through the “Go to videos” link, there are three video vignettes. Two of the individuals are black. Again, one wonders: Do the ads come from the clinical diagnosis? Or does the overdiagnosis come from the ads?

The other long-acting injectable antipsychotic medications are now available as generic formulations, so their websites are full of text. My efforts to find past advertisements, commercials, and press kits for them yielded no images. I find that interesting, too.

To be clear, these ads comprise a small sample and are for a specific form of medication. I don’t know what advertisements look like for all other psychiatric medications. Maybe I am reading too much into these websites. However, when (1) local, regional, and national data indicate that people of color, particularly African Americans, are more likely to receive a diagnosis of schizophrenia, (2) medications used to treat schizophrenia often have significant side effects of sedation and lethargy, and (3) these medications are available in long-acting forms, it makes me wonder.

Categories
Education Medicine Nonfiction Reflection Systems

I Have No Plan.

We learn about SOAP notes early in medical school:

S = Subjective, or what the person reports to you

O = Objective, or the data you gather from the person (vital signs, physical exam, lab studies, etc.)[1. We’ll put aside for now the discussion of the problems with labelling these sections “Subjective” and “Objective”.]

A = Assessment (a diagnosis and formulation based on the Subjective and Objective data)[2. We’ll also put aside for now the potential problems that arise at the intersection of billing and diagnosis.]

P = Plan (the next steps or recommendations that occur as a result of the Assessment)

Most medical notes, regardless of specialty, setting, or length, follow this SOAP format.

While recently typing up some notes, I blurted to my colleague, “What I really want to write under the ‘Plan’ section of my note is, ‘I have no plan’. Can I do that?”

Sometimes the Plan is direct and clear:

S: Mr. Doe reports that he hasn’t heard voices in three days. He finds it easier to read books. He denies side effects from medicine.

O: He isn’t talking to someone who isn’t there. He’s not demonstrating tremors. He’s showing more emotional expression in his face.

A: A psychotic disorder that could be due to This, That, or The Other Things.

P: No changes in medication. Continue to encourage activities he enjoys. Cheerlead his ongoing efforts to monitor his own progress. Follow up in a few weeks.

Sometimes I have a Plan, but it’s not a Plan I write down because the next steps or recommendations are beyond our control:

S: Ms. Doe reports that she uses methamphetamine to help her stay awake at night. She fears that if she falls asleep, men will hit or rape her. She still hears voices. They have gotten more intense since she left her foster family a year ago, as a member of the foster family was molesting her.

O: She’s distracted, looks exhausted, and, since she doesn’t have a safe place to stay, has little interest in reducing or stopping her use of methamphetamine.

A: Methamphetamine use disorder. Some flavor of a trauma- or stressor-related disorder. Maybe an anxiety disorder? Maybe a psychotic disorder that could be due to This, That, or The Other Things?

P: (1) Ensure that people have safe places to live. (2) Stop human beings from sexually assaulting other human beings. (3) Instill proper ethics and morals into all of humanity.

Then, there are times when the Plan doesn’t include concrete steps that will guarantee forward movement:

S: Mr. Doe was reluctant to talk to me. He only shared that his words are potent and, if he misspeaks, my face will melt off. He said that he doesn’t want to hurt me or anyone else with his power. My efforts to inform him that my face will remain intact were unsuccessful.

O: He’s eating, he’s sleeping, he avoids other people, and this is the most he’s spoken to anyone.

A: Probably a psychotic disorder due to This, That, or The Other Things?

P: ???

Since I have to write something, the Plan in these situations usually looks like this:

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P: Continue to build rapport as tolerated. Gather more history. Will try to talk to him again in X amount of time.

The most difficult notes to write are those when I know I have no plan. This is distinctly different from not knowing what the Plan should be. (This is a function of time and experience, of knowing what I don’t know.) These situations usually involve a combination of the last two situations I described:

S: Ms. Doe said that there is a dead baby inside of her. Records state that she has reported this for the past four years, though there is no evidence that she has been or is pregnant. She was the victim of a significant assault five years ago; she sustained head trauma from this event, which many believe is the cause of her erroneous belief. She visits emergency departments multiple times a week due to her belief that there is a dead baby inside of her. She has assaulted both of her parents multiple times, so they have filed “no contact” orders against her. Because she now has no place to live and her anxiety about a dead baby inside of her persists, her behaviors sometimes result in law enforcement encounters, which land her in jail. She has avoided psychiatric services because she insists that her belief is true.

O: When she does talk, she speaks with dread and grief about a dead baby inside of her. Other times, she screams, demanding that people leave her alone. When she menstruates, she smears the blood all over herself while crying, mourning the loss of what she believes is her dead baby.

A: A psychotic disorder probably due to the head injury, but maybe due to Other Things?

P: … [I have no plan. I just don’t.]

The best Plans are those constructed with the person in question. Unfortunately, Ms. Doe usually doesn’t have a plan, either. So, I write down the little I can actually do:

P: Work with team to build rapport as tolerated. Find out what else she cares about. Work with other systems to create a plan to help reduce her distress without causing more trauma.

… and hope that patience and persistence will reward us in the future. Because sometimes hope seems to be the only thing we can do.

Categories
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.

Categories
Observations Systems

Devastation and Vulnerability.

We are all devastated that children died. Again.

Even though we know that the causes are complex, we want to reduce the issue down to one factor.

“There’s not enough access to mental health services!”

“Agencies with oversight didn’t do their job when they learned concerning information!”

“We need gun control!”

It’s complicated.

We are all devastated that children died. Again.

When kids of color die in mass shootings, do they get the same front page headlines? prime time coverage? threaded tweets with tens of thousands of likes?

Many people who own guns never shoot people. They never craft plans to kill other people. They don’t have impulses to kill themselves.

Is it fair to blame only guns and take them away from people who own them, when most are responsible citizens?[1. To be clear, I do support more regulation on firearms. It is possible to support responsible gun ownership AND gun reform.]

Many people with psychiatric disorders never kill people. They never craft plans to kill other people. They don’t have impulses to kill themselves.

Is it fair to blame only psychiatric disorders and the people who experience them, when most are responsible citizens?

We are all devastated that children died. Again.

Many have expressed displeasure with the wide and toothy smile in the photo, his thumb extended for all to see.

Is it fair to blame only him and his administration, when nearly 63 million people voted for him? Most of whom are responsible citizens?

We are all devastated that children died. Again.

This devastation is a reaction to learning the news that young people died through no fault of their own.

Was the murderer’s decision to kill young people at a school a reaction to something else? Was it a self-contained reaction, a reaction born solely of the release and reuptake of serotonin and dopamine and epinephrine and acetylcholine?

Or was it a reaction to the trauma that all young people experience as they live through the cruelties and injustices of the world?

Why was this—killing students with a gun—his reaction?

What is the reason behind your reaction to him?

Or is your reaction due to multiple reasons?

Are we all blind to the hubris of blaming one thing, one condition, or one person? How are we so sure?

We are all devastated that children died. Again.

To sit with our devastation, to embrace it and understand how it affects us, to witness how it shapes what we say and do, is hard. To acknowledge that our emotions don’t feel under our control, to realize that feeling pain makes us vulnerable, is hard.

It’s hard for everyone else, too.

We must accept and respect the vulnerability in ourselves and others if we want our reactions to change. Only then will the devastation will stop.

Categories
Homelessness Nonfiction Policy Systems

How to Prevent All of This?

Some of the people under my care in the jail right now are quite ill. (This statement is always true, but it seems that the intensity of illness is greater now than usual.) As a result, the perennial question seems more urgent now: Is there any way to prevent All of This?

For some of them, it seems that the answer is No. Some of them sought out psychiatric services, attended appointments regularly, and had good working relationships with their physicians and therapists. They shared their concerns with friends and family members; they sought out help when they started feeling overwhelmed. Despite these relationships and support, they allegedly did things that resulted in significant criminal charges. And now they’re in jail.

For some of them, the answer might be Yes. Maybe if they had more people they trusted in their lives; maybe if they had a better connection with the counselor or doctor they saw that one time; maybe if their friends and family had more time and resources to seek help with and for them.

Then again, for some of them, the answer might be No, but for frustrating and sad reasons. Maybe their friends and family did everything they could to help them, but they didn’t want their aid. Maybe they became so fearful for their safety that they withdrew from everyone and, in isolation, their symptoms became worse. Maybe they believe that they are fine; it is the rest of the world that is confused and ill. Maybe their only experience with psychiatrists was involuntary hospitalization: Who wants anything to do with a system that takes away your rights and forces you to accept medication?

Some of these people are so young. To be clear, it’s troubling whenever someone of any age ends up in jail solely because of psychiatric symptoms. But can you imagine being 18, 19, or 20 years of age and landing in jail in the midst of hearing incessant, taunting voices, believing disturbing things that simply aren’t real, and having no visitors because the few people who are in your life are scared of you?

It’s heartbreaking.

At least these individuals come to clinical attention. And many get better: They form relationships; they talk with my colleagues and me; they learn how to get along with others; they reflect on what has happened and how to avoid similar consequences in the future; some take medication to help reduce their symptoms.

But then I think about all the people who never encounter law enforcement and never enter the criminal justice system, but they also experience significant symptoms. How do we prevent All of This for:

  • the man who doesn’t tell anyone any personal information and stuffs his tattered clothes with plastic bags to stay warm
  • the woman who won’t move indoors because she believes that the aliens will execute her if she does so
  • the woman who won’t leave her house because she believes her neighbors are cannibals
  • the man who sits all day on the sidewalk across the street from his old employer because he believes that he will get his job back

What about them? How do we help those individuals when the system ignores those who cannot or will not play by the rules?

Many mornings I see the same woman standing near a bus stop. The bus stop is covered, but she never stands underneath the awning. She stands behind the bus stop, even when it’s raining.

You can smell her—a mixture of sweat, dirty socks, and yeast—from several feet away. Pedestrians move around her the way water swirls away from large rocks on the riverbed.

Two black garbage bags sit at her feet. They are full. Plastic zip-lock bags poke out of one of them.

She is a young woman of color. She wears a dark hoodie that is too large for her slender frame, but it’s not zipped up all the way. She’s not wearing anything underneath the hoodie, not even a bra. An unwashed skirt smeared with dirt covers her legs. Her mangled sandals reveal that she has not clipped her toenails in many months.

She talks to an unseen audience and everyone can hear what she says. Her voice is rich and though her sentences do not make sense, she speaks with dignity.

The other morning the rain wasn’t the usual mist that falls from Seattle skies. The droplets were full and heavy, a shower of dark water as the sky was filling with grey light.

No one was standing in the bus shelter. Her clothes were already damp.

“Excuse me?” I asked. She had raised an arm to make a point in her discussion.

She fell silent and blinked a few times.

“Do you want to move so you’re under the bus shelter? So you won’t get wet?”

She turned her head and looked away.

“I can help you move your stuff. It’s raining pretty hard right now.”

She dropped her arm and turned her head further.

“What’s your name? My name is Maria.”

She glanced at me, raised her arm back up, and resumed speaking: “All in all, we must to the left….”

I stood there for a moment, waiting for a sign. None came. I walked away.