You May Be Right (We May Be Crazy)

A humanities friend of mine asked a question in response to the last post: if the intern workload produces bad incentives and potentially suboptimal care, not to mention emotional burnout/family trauma/car accidents[1]/general crabbiness, why the heck do we do it? There are certainly plenty of people who want to be doctors, not to mention the number of nurses/physician assistants/other providers who'd love to extend their scope of practice. Why would we set this up so that so much burden falls on the most junior (i.e., least competent) doctor? Are we, in fact, just nuts?

This is a question I work on quite a bit in my organized medicine activities. The answer is tricky. There is some of the problem that's good old-fashioned "I did it, I suffered, now it's your turn" mentality. But, there's also good economic reasons for it, and that's really what keeps it going (in my opinion, anyway). The economics from the hospital's side are simple. The median salary for a nurse practitioner in Seattle (if you believe salary.com) is about $90,000. My pay, as conveniently advertised on the web, is half that. I don't have a union, I don't have to be paid overtime when I work beyond 40 hours, and in general, I do perhaps 1.5 times the work (as measured by hours; productivity would be less) of a free-market NP for half the cost. If I save the hospital perhaps $50K a year, and there's at least 400 residents in the hospital, that's $20 million a year. That's not even counting the extra revenue that the surgical residents can generate because of the extra volume in high-reimbursement procedures.

It isn't just one-way exploitation, though. In theory, it's also designed to benefit me. Between the cap on the number of residents Medicare will pay for, and the general tight-fistedness of the accrediting bodies, the residency system acts as a choke on the physician supply. As you'd guess if we're working almost 80 hours per week, the supply is controlled to a level substantially less than demand, and has been for decades. Econ 101 tells us that high demand and low supply equals an increase in the price of the good. Or, in other words: the residency system creates an artificial scarcity of doctors in almost every specialty, leading to recruitment battles and higher physician salaries [2]. One of the major reasons everybody tolerates this system is that (again, in theory), in exchange for getting hosed while you're a resident, you thereafter get to be permanently employed with a salary in the top 3rd to 5th percentile. It also lets you feel a bit prestigious -- sure, you work hard and maybe it messes up the patients, but think about how much better you are than all the people who applied for your job but didn't make the cut!

The interesting thing is that aside from the twin profit motives above, there's a very anti-profit motive that also props up the system. Somewhere along the way, we acquired the notion that excellence in doctoring is comprised mainly of working harder. In general, many physicians' solutions to the problems facing health care as a whole, or individual patients, is simply to throw more of their own person-hours into the furnace. We're quite proud of it, too. We'll regularly boast about how many extra hours we put in to get the job done for that one particular patient. Whoever self-inflicts the most suffering is somehow ennobled. It's hard for me to say where this mindset comes from; as you can guess from my tone, I don't think it's quite right. You can't build a sustainable health care system on the notion of individual heroism. Yes, it's nice to know you've got the doctor who'll go the extra mile -- but do you still want him when, as almost inevitably happens, he burns out and loses the ability to care altogether? More importantly, who among us hasn't been told approximately a trillion times to "work smarter, not harder"?

And that, in the nutshell, is the real reason why a system persists even though it probably doesn't do anyone (except maybe the hospital management) much good. We could design something better, but to do so goes against the #1 survival skill taught during training: keeping your head down, working harder, and just plowing through. Furthermore, everyone's so focused on the short-term gain they expect to get out of the system that they ignore the broader interest. Unless physicians of all stripes get together and make the teaching system more sensible for doctors and patients alike, we're going to be so busy with nobly working harder that we won't notice while all those traditional prerogatives of the profession (prestige, money, the "right" to be "in charge", even being the only person on the team who's called "Doctor") get carved up and carried away by the many other players in the modern health care enterprise.

We willingly and perhaps even knowingly perpetuate a system that messes up our future colleagues, sets us up for economic problems in coming decades, and doesn't do any better by the patients. We are, in fact, nuts, or at least just really dumb. Unfortunately for me and many others, this turns out to be yet another one of those diseases I can't fix -- at least, not yet.

---

[1] All of the above are, in fact, documented in the peer-reviewed literature. Yes, car crashes. It's in the New England Journal of Medicine. Brings new meaning to "work yourself to death", no?

[2] Econ 102 goes on to explain that supply-demand curves are ironclad unless a substitute good is available at a lower price. And that NP may be expensive at $90K... but he/she is a lot better than the median psychiatrist salary of $200K. (It's about the same for a hospitalist in general medicine.) So in fact, a rationally-acting hospital or health insurer will not pay physicians what they expect, but will instead substitute cheaper products when possible. The storm coming from that particular collision in expectations is another entry unto itself.

Three More Weeks...

I've been off in a wilderness called "medicine" for the past two months; all psychiatrists are expected to do four months of general medicine training in our first year. Mine is split as one month of adult inpatient, two months of pediatric inpatient, and one of adult emergency (which everyone loves, because it involves neither call nor morning rounds).

As you might surmise from the months of sudden silence, it's been busy. It's not just the call, though. It's taken me a while to adjust emotionally to a very different environment and a different way of taking care of patients. There is, obviously a lot less talking to your patients, and a lot more talking about them -- presenting them to the attending on rounds, telling consultants about them, talking to their nurses, calling radiology about their x-rays and CT scans, calling social work to arrange discharges, and so on. For someone who went into psych specifically because it's the specialty where you get to spend an hour minimum with every new patient, that's less than desirable.

The bigger issue, and the one that constantly frustrates me, is that medicine wards everywhere are basically set up such that my survival depends on taking bad care of patients. The issue is simple: a medicine intern's patient load is not fixed, as it is on psychiatry. In psych, we have a bed shortage, nationwide. As such, the inpatient units are always full. The workload has been calibrated such that taking care of a full unit will be difficult, but still doable while keeping work/life balance (and attending to all the non-patient-care items that constitute "work", such as conferences, research, reading, teaching, etc.) No so the medical floors. Every intern has a variable census. At Harborview, our adult hospital, you can be responsible for up to ten patients. Roughly speaking, you're required to pick up five more every fifth day when you're on call, plus two more in the middle of the call cycle -- seven additions every five days. You keep caring for them until they leave. The problem is simple -- nobody can take competent care of ten adult medicine patients. The paperwork and diagnostic/treatment load required is beyond a junior doctor's faculties. The actual "happy medium" for learning varies, but mine is somewhere between five and seven. At Seattle Children's, where I am now, it's similar but without the cap -- each call night could be anywhere from three to ten patients, and I've had my service hit thirteen[1]. (Thankfully, at that point the senior residents took mercy and did some redistribution before I died.)

In such a system, all your efforts have to focus on one thing: get the patient out the door as fast as you possibly can. When you're on call, the principle is similar: do the minimum necessary work on each new patient, because a flurry of admissions or a serious crisis on existing patients could happen at any minute. It's a constant race to get ahead of the tide. Personally, I feel that this leads to suboptimal care; maybe not actually "bad", but definitely not the care I'd want my own family to get. How can your doctor truly care for you when all his/her incentives are about minimizing contact, minimizing time, and getting you just stable enough to be hustled out the door? It does function -- most patients don't get readmitted, at least not immediately. It just doesn't provide the quality I'd want from the world's most expensive health care.

Of course, it's not all bad. I'm not going to say it's educational; the actual amount of learning about medicine is minimal. Mostly I learn how to do paperwork and what this particular hospital's protocols are. At best, it's an exposure to ward workflow so I can be more helpful in second year, when my primary role will be consulting psychiatrist for those medically ill patients who also have mental health needs. What it does do is really make you appreciate your free time. I find myself being more efficient in my days/hours off, because I know the clock is about to start again. I also think I will never again complain about psychiatry's less-than-once-per-week call schedule.

The other nice thing is occasionally getting one of those medical patients with psych issues, because for once, I can take care of someone from both angles. The average medical resident tends to be profoundly uncomfortable with someone who's suicidal, or majorly drug-addicted, or psychotic. I'm no expert on any of those, but at this point I've seen them enough to not panic. What I don't yet have is enough experience in the management of the many kinds of toxic overdose, or the infections that result from IV drug use, or the complications of rampant diabetes. Having someone teach me about those while I get to also treat the psychiatric problems is profoundly satisfying, and almost fun. I've daydreamed about trying to find a way to make more of our "medicine" time focus around that scenario, but haven't quite come up with it. It'd require having a kind of dual-attending med-psych service and the underlying administrative structure; a great project for a chief resident to undertake, but not really doable by an intern (at least, not one on medicine months).

In the long run, mostly the past two months have confirmed to me that I picked the right specialty. Some of the patients were interesting, the pediatric ones are cute, and a few have even been grateful. Still, if you told me I was going to spend the rest of my life managing electrolytes and infections, I'd quit and go back to the lab for good. There's only three (ish) more weeks and six more call nights before I get to put off the white coat, mothball the stethoscope, and get back to shrinking heads. It's good to be in the home stretch.

---

[1] The astute will note a potential upside -- if you are REALLY lucky and get just the right kind of simple admissions a given call night, it is possible to actually discharge everybody before your next call. This has happened to me twice in my three months; it's a magical feeling.

The Needs of... Who?

The needs of the many outweigh the needs of the few.

-- Spock, stardate 8130.4 (or thereabouts)

One of the biggest unspoken challenges currently facing all of medicine is a simple question: who do we serve? This seems obvious at first glance; we serve the patient. But who is our patient? Do we consider only the person who is in front of us right at this very second? Or should we step back for a second and consider all the other patients currently under our care, or all the teeming millions who might someday need our help? And if we think about them, what obligation do we have to them when we're thinking about what we do for the guy or gal in front of us?

We can argue until we're blue in the face about how much health care should be as a percentage of GDP, or what amount of taxes is fair to ensure universal coverage, or how much any given drug should cost. The answer to any of those doesn't change the general truth that resources are finite. An academic center may have six CT scanners, but it has six, not twelve. When my patient slips and bumps his head at eleven PM, does he or does he not get a CT of his brain? If all I care about is his individual welfare, chances are he gets the CT. The radiation dose poses relatively low risk compared to the potential harm of a bleed in his head, to say nothing of the potential harm to me and my hospital if he had said head bleed and I chose not to look for it[1]. But, let's stop and think for a second about those six scanners. We have a busy emergency department. If my patient is in the scanner when a trauma or a stroke rolls in the door, that's fifteen minutes longer they're waiting for their turn. Fifteen minutes in a stroke is a hell of a lot of potentially dead brain tissue, and that CT scan is critical to determining whether the patient can get clot-busting drugs. Fifteen minutes in a severe abdominal bleed is life versus death, or at the very least a question of several extra days in an ICU. Is this likely to happen from ordering one extra CT scan? Of course not. But an inpatient physician will order thousands of such scans over the course of a career. Roll the dice enough times and you're bound to make a losing roll eventually.

Even when the scan doesn't tie up resources someone else needs, it still uses resources. There's techs, and orderlies, and nurses. Their time gets billed for. IV meds get billed for. Wear and tear on the scanner gets amortized. Somebody's gotta pay. Sometimes it's the patient. More often, it's their insurer, which ultimately means, it's everyone else in their patient pool. That's a penny or less to the other patients, but multiply a penny times the number of patients your insurer covers, and that's Real Money. Either your premium goes up (which stresses you, causes you to cut back in other areas, and generally worsens your health) or your insurer cuts costs elsewhere (which deprives you of a benefit you otherwise might have gotten). This is a serious deal. With one relatively cavalier penstroke, I and every other doctor in this country can start off cascading events that seriously mess up the lives of large numbers of people.

Which brings me back to the question: am I, ethically speaking, required to take that into account? The Declaration of Geneva[2] says "the health of my patient will be my first consideration". The majority of attendings (the ones who aren't themselves relatively fresh from residency) are of the opinion that my patient is My Patient, that it is my moral obligation to provide whatsoever they might need, and to not do so is a breach of fiduciary duty. I, coming from a background in policy, as well as being the sort of annoying person who'll pick other people's soda cans up to throw them in the recycling, lean more towards conserving resources for the people who truly need them. The result is that I am either a very good doctor, or a very bad doctor, depending on your personal values.

This comes up a lot, especially in psychiatry. Psychiatry attendings haven't practiced general internal medicine in years. They thus have a relatively high level of anxiety about medical symptoms evidenced by psychiatric inpatients, and will almost always err on the side of getting a consult, or doing a test, or otherwise intervening. This tends to bother me. On the other hand, I am an intern, so therefore (A) don't know Jack and (B) am not the one whose posterior is on the line. Thus, I tend to shut up and order what is suggested. It causes me a great deal of internal conflict, hence this post.

When we talk about "controlling health care costs", one of the things we're talking about is finding ways of enforcing this idea that the collective good outweighs the marginal benefit that might accrue to any one individual patient. That means cutting back in some way on doctors' autonomy, and it means changing a value so ingrained in medicine that it might as well be one of the Ten Commandments. It also means realizing that the guy in the white coat isn't going to be 100% on your side anymore (if he ever was). It's likely to happen. It might even be inevitable. Still, for most people, that's not a happy proposition.

---

[1] Some may argue that the liability issue is really the thing driving my decision to scan. They are probably not wrong.

[2] The artist formerly known as the Hippocratic Oath.

Mike and the Demon Rum

The recent blogging hiatus is because your humble narrator was off getting married. That is now accomplished. In the calendar year of 2009, I'll have lived for three months in the Third World, moved across country, started a new job, gotten married, and possibly have sold my house (condo). No wonder I feel exhausted. At any rate, I'm committed to getting back in the blogging saddle and putting more ideas into words.

To set today's scene, I'd like you to pretend you're sitting in an emergency room. This is not the bright lights and bustle you see on "ER". A psych emergency center involves small, windowless rooms without furniture, wall fixtures, or much of anything else. You bring in a plastic lawn chair to interview. At the moment, it's about 2 AM, and you're sitting across from a guy we'll call Mike. Mike is here because he's feeling suicidal. He's been here a while; when he came in, he had a blood alcohol of 450, and you've been waiting for him to sober up enough so you can talk. (For reference, at 200 mg/dL, a "normal" person should be staggering, falling-down, blacking-out drunk. At 400, you or I would be comatose and on our way to dead. Mike was walking and talking, albeit incoherently.)

Sometimes Mike is fat, sometimes he's thin. He's usually in his 40s. He often has tattoos. He's always alone. The story has some variations, but in the aggregate, it goes like this: Mike started drinking young. Sometimes his daddy did too. But, at the start, Mike had a job, a wife, usually kids. Eventually, though, he was hitting it harder and harder, and he lost his job. So he went into treatment, finally. That got him sober -- for a few months, tops. Lather, rinse, repeat. After two or three cycles of this, his wife finally left him. He moved around a bit, staying with family and friends, repeatedly trying to get it together. Slowly, inevitably, he burnt out those supports too, and ended up living in his car. When the car stopped running, got stolen, or just plain got lost, he joined the ranks of Seattle's homeless.

Mike has been in every kind of hospital you can imagine. Outpatient chemical dependency treatment. AA. Inpatient treatment, sometimes for months. Sometimes he's even tried aversion therapies, where they forced him to drink while administering a medication that makes it painful to ingest alcohol. In the hospital, he gets clean. He wants to be clean. He really does want to give it a try. But, when he gets released on that final day, he gets nervous. He thinks of all the times he's tried this and it hasn't worked. He thinks of how alone he is now, of everything he's lost. That old, familiar anxiety worries at him, and a few hours later, he's opening that can of beer or that bottle of cheap liquor.

Mike's problem now is that, even though he's on public assistance, the county will only pay for so much inpatient time each year. So, chances of him getting inpatient detox, inpatient alcohol rehab, or even ordinary inpatient psych are pretty slim. Your task now, in the middle of the night, is to figure out what to do with him. He did say he was suicidal -- but according to the notes in the computer, he always gets suicidal when he's been drinking, and wants to live again when he sobers up. There's also the fact that withdrawing from alcohol might kill him. You see, while alcohol might not be as addictive as heroin or crack, it can be far more deadly. Withdrawing from most street drugs is painful, but ultimately just involves feeling like an utter wreck for a week. Withdrawing from alcohol involves tremors and an altered mental state -- the legendary delirium tremens. If your brain is sufficiently dependent on alcohol, we progress to seizures, and then to seizures of the autonomic nervous system that regulates your circulation. Either you get some alcohol in you, you get a sedative that acts on the same receptors, or your wildly-firing brain actually drives your heart to stop beating.

So, in theory, you could just let Mike hang out in the ER for a bit until he decides to leave. He won't seize immediately -- it takes a day or two to get there. If he leaves, he'll drink, which will solve the problem of withdrawal. If you're feeling like he has a good story and you have time to argue on the phone with insurance authorization, maybe you can bring him in. He can get meds to ease withdrawal and taper himself back to sobriety, then get discharged to a halfway house. Of course, if you think you're going to magically break his addiction, you're more delusional than the patients. Alternatively, you can let him go. He'll drink, and eventually he'll be publicly drunk and get arrested. Jail will sober him out and maybe even court-order him back into treatment. That is, assuming he doesn't fall off a wall, or in front of a car, or into the bay. Or drink, get suicidal, and take that final step off the Aurora Avenue Bridge. Options aplenty, but good options are scarce.

Everyone, including Mike, wants him not to drink. The problem is, nobody understands why he does. You or I don't do this. There is something in his neurons, something specifically tuned to alcohol, that pulls him to drink like a magnet. It's not just personal weakness. This is beyond that -- it's a need that's almost as bad as the need to keep breathing. Some of it is certainly inborn. If we caught it early enough, maybe we could have undone the rewiring, kept the brain from learning this deep dependency on the drug. Instead, as Mike kept drinking through his 20s, it burned itself in deeper and deeper. As one after another social support burned out and cut him off, the restoring forces that would pull him back to sobriety disappeared.

There's no moral or easy answer at the end of this story. I don't know what to do with the Mikes who show up at my door. I try to get them referrals, and if they want to come into the hospital, I usually let them. The only thing it really changes is helping me feel like I've done something for a fellow human. It also reminds me why I wanted to be a research psychiatrist as opposed to primarily a clinician -- there's a whole lot of Mike out there, and right now, we're letting them down.

Stranger Than Fiction

Today, my medical student and I had the chance to accompany one of our patients to court for an involuntary commitment hearing. Picture, if you will, a small courtroom, not entirely unlike a TV courtroom without the audience section. The defendant, a rather large woman, has three of her four limbs restrained in a wheelchair. She is carrying several rolled up wall-chart pieces of paper, and is sitting with a blanket over her head. She states that she has fired her public defender and wishes to represent herself. The judge does allow this... for about two minutes, at which point it becomes clear that the patient has no concept of what this trial is about, or about law in general, and thus the public defender is reinstated.

Once the trial re-commences, the patient states that she wishes to speak on her own behalf. This motion is granted. She removes the blanket from her head and proceeds through her series of charts (which are covered with semi-sensical diagrams and random technical phrases), becoming louder and angrier. After running out of charts, she states that "You want to know my evidence? Here's the evidence against you!" With this statement, she proceeds to lift up her hospital gown, spread her legs (to the degree that one can do so while restrained), and, um, manipulate herself. The judge's bench happens to be positioned such that our esteemed jurist has a view pretty much straight down the barrel.

I tell you with the greatest respect and amazement that our judge did not bat an eye or in any way become agitated. She continued the trial, her face perfectly composed, and merely asked whether a blanket was available to cover the patient. A blanket was provided, the trial resumed, and the patient continued to engage in her behavior, but mercifully away from our eyes.

It's not quite a Johnnie Cochran strategy, but it certainly did make an impression. Fortunately for our patient, it made the right impression and she'll be spending a few months on mandatory hospitalization so we can get her back to normal.

One More Jane

I've changed hospitals as part of our rotation, and am now at the county hospital. It's quite different from our voluntary University unit, as you'll hear in a future entry. In the meantime, as the health care debate continues to rage, the story of one patient I saw at the U just before transferring, and what it means for the American health care system.

I'll call her Jane. That's not her original name, obviously. When she was a young girl, Jane was raped/molested by an older male relative. She suffered through it for a while, but ultimately it came out in her late teens, caused a ton of family turmoil, and landed Jane in the hospital while she worked through her trauma. Despite this, she ultimately thrived, graduating from a well-known East Coast university and landing a series of interesting and decently-paid jobs in her field of study (one which turns out to be, in general, hard to find a job in). She overcame a battle with some very unpleasant cancer, despite some permanent functional impairment from the surgery. She even had children, although without a supportive spouse to remain in the picture for her.

Then, one year ago, lightning struck twice and Jane was sexually assaulted again. As she was dealing with that, the recession and political factors combined to eliminate her job. She persevered, looked for work, but ultimately realized she needed to draw on family supports, and came home to Seattle. Without a job or health benefits, she ended up living in friends' homes and sending her children to stay with their grandmother and great-grandmother nearby. She felt anxious and unsettled much of the time, but kept the same brave and cheerful outward face she always had. Tending to her own mental health was not high on the priority list, although she did find a counselor who would work on a sliding-fee scale.

And then, as one might expect with someone who's had a history of trauma and is now facing major life stresses, Jane started to come unglued. She'd always had nightmares about the abuse; they began to get worse. She began to have frequent panic attacks, and avoid even places like the grocery store, for fear that being out around others would trigger her panic. And then, one Friday, as her host family was headed away for a weekend, she began to have thoughts of shooting herself with the gun they kept at home. Jane had the sense of mind to get herself to a hospital and thus get sent to my inpatient unit, where (apparently for the first time) I informed her that she was showing classical symptoms of pretty significant post-traumatic stress disorder.

After about a week of getting started on some medications, participating in our therapy groups, getting some of her chronic medical issues tuned up, and generally getting a break from the world, Jane was doing a lot better. She still had the occasional panic attack, but not as bad, and her nightmares were under control. Most importantly, she'd finally found ways to get her anxiety sufficiently handled that she wasn't thinking of ending her own life. All well and good, but now we had a problem: how could she continue this outside the hospital? We'd chosen the cheapest medications we could, but they were still $100 or more per month. Moreover, she'd need someone to prescribe them for her on an ongoing basis, because hospitals can't really act as long-term management.

And so we turned to that evil bastion of socialism, the government. Specifically, Medicaid and Washington State's General Assistance for the Unemployable program. The only problem: Jane had to be unemployable. Was she, really? It depends on your point of view. The Jane who showed up on my unit that Friday night couldn't handle a grocery store, let alone a demanding work schedule. Disabled by mental illness? You bet. But the Jane who was leaving us was capable of holding down a job -- IF she got ongoing treatment. And thus, we came to the Catch-22 underpinning much of the "safety net" health system -- you can only have health care if you stay sick. Jane's only way to get better... was to make sure she didn't get better, or at least, to convince some physician somewhere that she wasn't getting better. Net result? One intelligent and potentially quite productive lady effectively taken out of the workforce and one more drain on the public purse.

It's pretty easy to see how this could go differently. How there could be a minimum safety-net plan for everyone. How health insurance could belong to the person, instead of keeping us all shackled to particular jobs. There's a lot of people standing up in town halls this summer trying to keep that from happening, because it would somehow make us not be America anymore. If they get their way, we'll continue to be a free country -- where people are free to force themselves to stay as pathetic and helpless as possible, because it's the only way to keep themselves alive. Where productive citizens are forced to declare themselves disabled and go on the dole, because hey, at least it's not socialism. (Which is true -- under socialism, a potentially productive individual would be forced off her duff and back to work.) People will die and suffer, many of them pretty ordinary hard-working folks who used to comprise the "middle class", but at least Jose the illegal Mexican won't get free health care. Well, unless Jose shows up at an emergency room, in which case he'll still get taken care of, because we're ethically and legally required to, and you'll still pay for it, either through taxes or higher insurance premiums.

Around the country, hospitals, and psychiatric units in particular, are full of an army of Janes. Jane won't show up to a town hall or think about writing her Congressman -- she's too busy trying to survive. You, on the other hand, have the time and the means, and there are people making it easy for you. You, or someone you love, are one bad day away from being the next Jane on the list.

Night Float

Tonight's my last night (for a couple months) of "night float", a lovely invention that reduces everyone's call stress. Basically, for the past two weeks, I've not had to come in during the day. Instead, starting at 6pm and going till 8am, I carry the pager. Anything that happens in the hospital that needs urgent psychiatric attention, it's my job. The really fun part of this -- no attending or senior resident in-house. Just me and a back-up attending available by telephone. Three nights a week, I've got a med student. And, at least at this hospital, it's home call. If something happens, I get my rear into the hospital; if nothing happens (as it blissfully has twice this week), I get to sleep in my own bed and mostly deal with requests for Tylenol over the phone. This is extremely conducive to wedding planning.

I'm still deciding why exactly I like this so much. One aspect is certainly the reduced amount of overall work -- I don't work the full 14 hours, and I do a LOT less paperwork because I'm not responsible for daily charting. Another is the fun of emergency diagnosis and treatment, a totally different beast from regular psychiatry. Regular psych is a longitudinal process of building relationships and slowly changing behavior. This is one of quick evaluations, decisionmaking with limited data, and planning in the moment of acute crisis. The decisionmaking in particular is nice -- as with regular emergency medicine, I actually get to try to diagnose, instead of treating something that someone else already figured out. The third, as noted above, is the autonomy. It's the only time when I am, for real and genuine, the Doctor In Charge. There's of course an expectation that I'll seek second opinion for any dicey judgment calls, but for 99% of stuff, I'm free to use my own judgment about what meds to give, how to manage the patient, and what not to do. I also get to experience the consequences of my own mistakes, e.g. getting called back into the hospital last night at 5:30 AM (after going to bed at about 12:30 AM) because I didn't realize a particular patient might be a fall risk. Experience is an excellent teacher.

And, of course, night is when all the absolutely ridiculous stuff happens, the stuff that becomes an intern's standard happy-hour conversation. In particular, at night I'm responsible for urgent consults. The past two weeks are two of the stranger consults I've ever done, even counting some odd ones as a med student:

1. I get called by the surgery patient to request a consult -- on a patient who's not in the hospital any more. You see, the patient in question has a habit of swallowing things when he gets upset, and particularly of swallowing dangerous things. Like, in this case, three razor blades[1]. The surgeons decided to wait and see if he pooped them out -- and in the mean time, kept him NPO[2] for days. They meant to call psych to see him, but never quite got around to it. And then, the patient left the hospital, because he was sick of his team. Eventually, he realized his stomach hurt and came back to get pain meds, and I did see him, after midnight (He wasn't thrilled about that either.) The ostensible reason was "Well, he's crazy, does he have the mental capacity to leave the hospital?" The answer was "He's not so much crazy as just a pain in the butt, and the patient himself says so. Yes, he has mental capacity. Sorry, you're stuck with having to be nice to him." (The official declaration of "not crazy" is a common reason for psych consultation, actually.)
   
2. Called to see patient in ED for suicidality. Turns out patient is deaf. And can't sign very well, plus no sign interpreter available. And can't read lips. And also is refusing to write any answers to anyone's questions. And, according to the deaf staff workers at patient's current housing, is suspected of not actually being deaf. And just moved to Seattle with no ID or anything, having apparently lost all of the above during multiple sexual assaults in another state. And is terrified of men. The diagnostic interview was... limited. To a single written statement of "I refuse to answer this question". Diagnosis: everything in the book. Plan: Keep on suicide watch until she feels like "talking", and refer for involuntary mental health commitment as presumed suicidal/grossly disabled until/unless she does "talk".
   

One of the many many things I love about psychiatry -- it NEVER gets boring. There may be a small set of diagnoses, but they present in a whole lot of different ways.

---

[1] You may ask how it is possible to swallow razor blades without getting the [bleep] cut out of one's tongue and oral apparatus. I don't know. Nobody I've asked knows. But it is, because this is definitely not the first patient I've met who does this.

[2] "Nil per os" = "Nothing by mouth". A very unpleasant state to be in for a few hours. For a few days? You'd be ready to punch someone.

What Do You Do With a Med Student?

One of the most exciting things for me about making the transition from student to resident is that I am now formally in a teaching role. Interns have more contact with medical students than any other member of the health care team, which means we're responsible for making sure they learn what they need to learn, as well as trying to model "good doctor" behaviors.

When I think about the interns I really enjoyed working with, they gave me leeway to actually do stuff on my own patients, tried to involve me in formulating the plan for a patient, gave me credit for work I did, and occasionally gave me knowledge that was useful for the upcoming exams. Now that I'm on the other side of the interaction and trying to behave the same way, I've made a perhaps-unsurprising discovery -- teaching well is hard.

As a student, I assumed my interns were fountains of medical knowledge. After all, I knew X, Y, and Z from my lectures and my nightly readings, so they must already have the same things memorized. I was wrong. Medical students, please take note: particularly in the summer, your intern does not know jack. Students have time and motivation to read in detail and memorize diagnostic criteria, subtle points of pharmacology, and so forth, and they have weekly lectures to cover these same topics. I use that same time to fill out paperwork and plan my wedding. Moreover, the older I get, the less appealing I find the idea of spending an evening memorizing lists. Hence, on most topics, the medical student actually knows the correct answer, whereas the intern does not. (I presume I, as an obsessive reader, must have driven my interns mildly nuts.) As a result, the med student can actually be profoundly threatening to one's ego. After you've been shown up two or three times a day by someone who's really just average for his/her class, there's certainly an urge to divert the pesky little twerp onto a many-hours-long paperwork or telephone task. Or, in some of the less gently specialties, to provide a few cutting remarks that make clear students should be seen and not heard.

Neither of those options being entirely palatable, I've had to find a new approach: teach primarily on things that aren't psychiatry. See, they may have all those lectures and do all that reading, but 99% of them focus it on the specialty at hand, since that's what the end-of-rotation test covers. It turns out there's a reason we still have MD/DO psychiatrists and haven't abandoned the field to PhDs -- there is a lot of general medical knowledge needed to competently diagnose patients and use these drugs, especially in the inpatient setting. Maybe I don't always know the side effects of every antipsychotic, but I can recognize common abnormalities on EKGs, I know how to interpret serum electrolytes, and I know a little bit about drug-drug interactions. Plus, I can try to teach that elusive skill of "efficiency", which separates the resident who sees his/her family from the one who truly does live in the hospital. Of course "efficiency" does often mean "OK, I'll write the note and the orders that I'm legally required to do, you do the phone calls and fax this prescription", i.e. a whole lot of scut.

I'll be really interested to see how the evaluations come back for these first few months -- I'm trying to give them responsibility and help them mature from students into doctors, but that also involves assigning them a lot of work and introducing them to the high-speed pace of modern medicine. Either I'm being a good mentor, or a slave driver, and I'm not sure which.

The Problems I Can't Fix

(Or, why current Democratic proposals for health care kind of suck, but are still probably a good idea.)

It's been an interesting and stimulating two weeks since last post. I got my very own medical student, and on Friday I had my first night of overnight call. Both are experiences I'll write more about, but after I've got a few more data points.

For now, let's talk about the (many) things doctors can't fix, by way of an example patient I saw this week. He came in to our inpatient unit this week, brought in by the police after being found trying to jump off one of our more lethal bridges. As you might imagine, he's depressed. VERY depressed. The problem is the chain of events that led up to his current level of depression:

1. He's got a strong family history of depression, including multiple relatives who died of suicide.
   
2. He happened to only find out about those suicides recently, when researching his family in order to find some inspiration to get him through a tough economic patch.
   
3. Because of the tough economic patch, he's been using his illicit substance of choice a bit more heavily than usual.
   
4. Poor income, combined with spending more on substances, has dug him into some pretty deep debt and left him about to lose his apartment, if not both his apartment and his job.
   
5. The just-about-to-be-a-toddler baby doesn't help with the financial issues or the life frustration.
   
6. His wife is not from this country, and thus has limited options as far as work goes.
   
7. His wife's parents, living far away, do not particularly approve of him as far as we can tell.
   
8. Because those in-laws have decided to bail him out of financial trouble, they're extracting a price: they want the marriage divorced and the wife and child returned to the country of origin.
   
9. His wife decided to inform him of the divorce, and of everything she's doing to pack up their apartment and get out of his life, as soon as he was hospitalized.
   
10. You want me to tell you about his what? His health insurance? See above list. Ain't none and ain't likely to be none anytime soon.
    

As you might imagine, "seething cauldron of emotions" doesn't even begin to describe this man. Read that list again and think about how good a shape you'd be in if it all happened to you over the space of a few months. There's depression, but there's also a ton of anger: at his extended family, at his wife, and most of all, directed (probably not fairly) at himself. At any given moment, he's barely able to decide whether he wants to laugh, cry, hurt someone, try to put it all back together, or run away from it all right over the railing of that bridge.

My job, by general consensus, is to make him "stable and safe". My tools are a chest full of drugs and one experienced social worker. The drugs can handle #1 and #2 on that list and combat his brain's natural tendency towards depression. That may or may not help #3. Plus, they'll only cost him $5-$10 a month. We can't get him a home or a job, but social work can at least plug him into services for the homeless (and he's been homeless before, not coincidentally during his last major depression), which at least mitigates #4. #5-9 inclusive is where we start to get to problems. Obviously, I can't fix his marriage or his social environment. Nobody can. However, that environment alone isn't what's going to kill him. Lots of people survive family strife and divorce. What's going to kill him is that he's got almost nobody to lean on during one of the most ego-crushing experiences imaginable.

We do, in fact, have a cure for that as well. We call it "psychotherapy", or "counseling" if you prefer. Get him plugged in to a good therapist in the community, plus someone who can keep his med prescriptions current, and he's got a solid chance of making it through this, given that he did it once before. Only problem: therapist and doctor visits cost money. The people who benefit from them most tend to be those with serious psycho-socio-economic stressors, i.e. people who don't have any money. "But wait!" you say. "Medicaid solves this problem!" Sure. When you can get it, i.e. once you can get the application, fill it out, get on the waiting list, make it through the waiting list (which gets longer during budget cuts and recessions, even here in the "blue states"), get the card, and then find a doctor who'll accept new public-insurance patients. While I don't know the system 100%, I'd estimate minimum three months to get that set up.

In short, we have little chance of bolstering against #5 through #9 because of #10. If we want to keep this man alive and allow him to return to his former status as a contributing and functional member of society, not to mention thousands of others like him, we need a better answer to health insurance. Leaving the Republicans out of the picture for now, the Senate, House, and President all have different ideas on that better picture, with a lot of mumbling about a government-run national public health plan. Do I really like any of these bills? No. They all involve higher taxes for me, and I'm already feeling a bit of sticker-shock in terms of how much gets taken out of each paycheck (being, for the first time in my life, subject to both income tax AND Medicare/Social Security tax). As a physician, I can say that they don't adequately fix a number of problems, including really crappy Medicare reimbursement policies, liability issues, the balance between specialties, and what the heck "we pay only for quality health care" means anyway. You can see the level of imperfection by the fact that the conservative medical societies are fighting the AMA over it, i.e. the closest thing we have to a unified medical voice is seriously conflicted on the matter. That said, we can continue to bicker about imperfection, ideology, and Not My Taxes, or we can actually try to do something and save some lives. Will it work first time around? Unlikely. But until we take some steps down the road, we haven't a chance of building a health system that will actually get my patient the things he needs.

There's a lot of rhetoric about waiting times for MRIs and heart surgery and other high-visibility interventions. Nobody notices the deaths that are racking up simply due to our own inaction. None of the proposals likely to see a vote this year are excellent; all of them are just-barely-adequate enough to be better than what we have now. That's politics. We can either accept imperfection, or we can just let people like my patient fall through the cracks and, ultimately, off of bridges. I promised I'd do whatever I reasonably could to take care of the patients who come to my door. As far as I'm concerned, that makes the right answer pretty obvious.

Letter from an Unfilled Grave

Today, I had the profoundly odd experience of reading someone else's suicide note. The person in question chose a particularly non-lethal method, and is chilling out on my inpatient unit. However, he left a three-page note to his family, which we found in the back of his chart. Reading it, even in a well-lit unit with lots of noise, is an eerie experience. We all, like Walter Mitty, walk around with a screenplay in our heads. Sometime today, you've daydreamed about the conversation you might have with a friend, or partner, or co-worker, if only there were no tomorrow and no consequences.

This note is one man's personal drama, poured out on the page. Without going into too much detail, it is the last lament of a bright, but nerdy man who was socially awkward in high school, never got the hang of this "dating" thing, and found himself approaching middle age without any hope of having the relationship he'd wanted for decades. On one level, it's heart-breaking, because this whole mess could have been prevented if only one person had reached out along the way. I think I respond to it in particular because I can see aspects of my own teens-to-twenties in his life, and realize how close I might have come to being this guy. On another level, it makes me want to strangle the patient. He deliberately kept all of this, including a suicide plan in place for years, carefully concealed from his family, friends, and everyone around him. One single "help me", and he'd have been in a much healthier place, years ago. In that sense, the note reads like a paean of self-pity and misplaced pride. Of course, that's depression for you. It distorts your world to the point that killing yourself seems like a more rational option than calling your parent or sibling. And, for all we try, our lovely society continues to attach such stigma to it that people would rather die than admit they're depressed.

This guy got lucky, or perhaps he finally managed to find a way to ask for help while preserving his ego. Either way, he's got a solid chance. I went to college and grad school with a LOT of people who aren't too far away from being him. Chances are, you know someone like this. Shy, nervous, a little geeky, but nice. You wouldn't date him, but he'd be good material if he just cleaned up a little and got over his fear of rejection. Or, maybe his problem isn't romance, it's jobs. Or research. Or any other failure-prone endeavour. Take a moment to think of whoever you know fits that description, and see if you maybe couldn't do one thing to get his head screwed on a bit more tightly. You might save his life.

Week One

It's now been about a week since I started work on my inpatient unit. I'd love to tell you an insightful and inspiring story about a patient I helped this week; that looks like it'll have to wait for the indefinite future. The truth is that like many inpatient services, medical or surgical, we can't fix long-standing problems. We're a service for short-term stabilization -- getting someone just to the point of not being suicidal, not being off-the-walls manic, not hallucinating too much. But, just like medical illness, psychiatric diagnoses don't exist in a vacuum. If you're just depressed, you probably won't get anywhere near true suicidality, because your family and friends will drag you in front of a doctor way before that. But, if you're depressed, AND you had a traumatic childhood that left you unable to cope with life stress, AND you use alcohol/drugs heavily to cope with your depression and life stress, AND you're not exactly highly educated/compensated because of the foregoing, AND maybe you've got some chronic health problems to deal with, then chances are that at some point, you're going to just plain lose it. (The polite medical word for this is "decompensate".)

When you do, you'll end up on a unit like mine. My job, as determined by your insurance company, the law, and general custom, is to patch up your psyche, whether it's by increasing or changing medications, getting you a bit of detoxification from your substance of choice, or just giving you a safe and quiet place to hide for a week. What I'd like to do is let you walk out of the doors a few weeks later as a complete and functional person. Unfortunately, I can't. This isn't just the limitations of the medications and my own developing psychotherapy skills; it's the limitations of the world. For 90% of my patients, what's wrong with them is partly in their brain, and partly in their world. Their entire living environment reinforces whatever bad coping strategies got them admitted in the first place. Moreover, those bad early experiences have been burning themselves into the allegorical neural pathways for decades. It's not biologically possible (to the best of our knowledge) to undo years of conditioning in a week, or even a month. The best I can do is boost up the brain chemicals, get some help from our social worker to tweak one or two environmental variables, and then send the person back to their environment with a list of suggestions. Sometimes, they follow them, and over many years, they get better. Sometimes, they don't. Frustratingly, I don't get to find out.

This is, of course, not to say that what I do is useless. Far from it. My short courses of treatment are the equivalent of duct tape and twine, but if you know what you're doing, duct tape can take you pretty far. Moreover, treatment is the difference between one suicide attempt, and a suicide attempt followed by another, and another, until the person finally "succeeds". What frustrates me a bit is the endless list of problems that must remain unfixed. Like all good little doctor-trainees, I've got a perfectionist streak a mile wide. It's very hard to leave valuable work undone, and even harder to look a patient in the eye and tell them that no, I'm just not going to help with that particular problem. I'm sure I'll get a lot more comfortable with that as the year goes on; I'm not as sure that this is a good thing.

Trepidation

Since most of my readers (at present) are not psychiatrists, I thought it'd be good to start with that perennial question, "So what do you do, exactly, as a psychiatrist?" Since the next four years are supposed to be a comprehensive preparation for independent practice, the answer is really "a little bit of everything". But, at least for the next year, the answer is "one month of ER, one month of medical consults, two months of inpatient pediatrics, two months of neurology, and six to seven months of acute inpatient psychiatry". (A month is 28 days, hence why we have thirteen of them.) Like most intern years, it's heavily focused on the inpatient (people coming in to a hospital, as opposed to being in a clinic) management of acute (seriously ill, potentially life-threatening, fixable in a relatively short timeframe) conditions. In my case, that starts with acute inpatient psychiatry at the main University of Washington hospital.

Most of you will be lucky enough never to see the inside of an inpatient psychiatric unit. In some ways, it's like the other inpatient medical units you may be familiar with. Patients see their resident (and med student, if they have one) in the early morning, get seen again by the whole team (including attending physician) in mid-morning, have medication adjustments, tests, etc. ordered in the late morning/early afternoon, and then spend the rest of the day hanging out while waiting for those orders to be implemented. On a given day, one or two people get discharged, and others come in to take their place; the residents spend their afternoons doing the basic intake exams and paperwork required to keep that machine running.

Psych units have two big differences that still leave me a little nervous (hence the title of the post). First, instead of a large team, psychiatric inpatient care generally means one attending, one junior resident (me), and maybe one med student. Everything else is nurses, therapists, patient care techs[1], social workers, and other extremely helpful support personnel. In practical terms, that means that for somewhere between eight and twelve patients, I'm where the buck stops. I certainly get guidance and supervision in diagnosing them and picking the right meds, but the goal is for me to take the lead and be the primary doctor[2].

On a medicine floor, I'm very comfortable in that role. Yes, I've been away from the wards for six months, but the basic treatment for heart attacks, pneumonia, COPD[3], and heart failure hasn't changed much. Plus, I've had those drilled into me on so many rotations that I think I can diagnose and manage the average case competently. Not excellently; I'm still at the "cookbook medicine" level, and if they've got multiple other diseases the algorithms start to break down. Nevertheless, competently. I don't feel like I'm there with psychiatric disorders. I've had a whopping two months of psychiatric training during medical school, of which the most recent was over a year ago. I do still have a gut feeling for the diagnostic axes, but the full criteria and drugs beyond the first-line obvious choices continue to elude me.

Ultimately, this is what every intern feels just before he/she starts (except the ones who are delusional about their own intellect; those guys end up killing people). It will pass, about the time I'm scheduled to rotate to another service. Moreover, it keeps me humble, which is a good thing. That doesn't make the butterflies stop flapping in my stomach.

---

[1] The artist formerly known as "orderly".

[2] In theory; different attendings are variable in the degree of autonomy allowed, and I'm sure I'll be on a short leash the first month or so.

[3] Chronic Obstructive Pulmonary Disease, fancy doctor talk for "done smoked too much and lungs have given up".

Beginnings

It's now half a week until I actually turn into a psychiatrist. Jennifer (my fiancee) and I arrived in Seattle on the 25th of May, found an apartment, had our stuff delivered on the 30th, and were finally unpacked by the 13th of June. We've had three weeks to explore Seattle and the University of Washington, and so far are greatly enjoying it here.

Despite it being a week till the start of clinical residency, I've been on payroll for two weeks in order to get a bit of a jump on research. This is a large (16-person) residency, with two spots set aside each year as "research track". That mostly matters in later years, when I start to get a little extra time that I can use for laboratory work instead of supplemental clinical training. However, waiting until then to actually start a research program would mean I'd waste a lot of time learning techniques. My hope is to use these first three weeks of June, plus little snippets of stolen time throughout intern year, to at least start climbing the learning curve and getting socialized to a lab. That also has the nice side effect of dipping me into the information stream of who's writing what grants, where the overall direction of the field is pointed, what projcts might start up soon, etc.

For these first three weeks, I'm hanging around with these folks, who might seem more appropriate for a neurologist or neurosurgeon than a psychiatrist. The trick is that their "Neurochip" technology might have some unrevealed applications in psychiatry. Without going into too much detail (although I want to talk more about this in a future post), there's growing interest in brain stimulation for medication-resistant disorders. It's a tricky field, because it raises the spectre of abuses committed during the lobotomy era. Nevertheless, given that we seem to have more problems with the medication armamentarium every year, it appears likely to grow.

My argument is that what's going wrong in a variety of mental disorders is feedback. Your normal regulation systems get out of whack, such that you're acting on impulses you normally wouldn't (mania), over-suppressing normal behaviors (depression), unable to regulate your fear responses (anxiety, PTSD), and so on. The whole point of the Neurochip is to establish new pathways (feedback loops) within the nervous system. Applied correctly, that's a powerful new tool for letting patients take some control of their own minds. It also might help resolve some very thorny ethical issues; more on that some other time. For now, I'm trying to learn as much as I can about the technology and experimental methods, so that I can plan preliminary experiments and get a little "proof of concept" going.

Introduction

This is meant to be my professional, "public facing" weblog. I'm still working out what purpose it's going to serve (besides narcissism), but I think a few goals are:

1. Keep my widespread network of friends and family at least vaguely informed about what I'm doing and why I'm doing it.
   
2. Provide me a place for introspection, feedback, and general thinking about the process of learning to care for the mentally ill.
   
3. Be yet another sympathetic (I hope) window into what mental illness can mean for individuals and families, and the complicated role of medical professionals in helping both of the above.
   
4. Give me a place to talk about my research activities and future plans, both to help explain to people what the heck it is I do, and also to help me think more clearly about what those goals really are.
   

So, why "Robotic Psychiatrist"? For one thing, "robopsychiatrist" is a strange enough word that it wasn't already reserved. Beyond that, I'm a psychiatrist (or I will be), and I work with robots on occasion. I also hope I can bring some of my prior robotics/engineering training to bear on psychiatry. People certainly can't be debugged the same way software can, but psych in particular seems amenable to a systems approach. The neurobiology of the disorders I'll be treating is (in theory) more of a whole-brain disorder than the specific and easily localized syndromes of neurology. Equally, it takes a whole system to care for our patients. Everyone thinks about the drugs, but those are one small piece of a much bigger picture. Successful treatment of mental disorders means not just pushing pills, but also making sure the patient has good family/community support, that someone's managing/coordinating their care, that they have access to crisis services, and that their disease is understood in the context of their whole life. Thinking about how to put all those pieces together is the kind of problem I tend to enjoy and (sometimes) be good at, which I think is part of why I was attracted to the specialty in the first place.

Of course, the first year is mostly training in acute inpatient medicine/psychiatry, so most of that will be starting and tweaking meds, but I hope I'll have a chance in there to talk about the human side of the job and the patients.