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.
Friday, September 11, 2009
Sunday, September 6, 2009
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.
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.
Thursday, August 6, 2009
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:
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.
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:
- 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.)
- 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.
Friday, July 31, 2009
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.
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.
Sunday, July 19, 2009
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:
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.
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:
- He's got a strong family history of depression, including multiple relatives who died of suicide.
- 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.
- Because of the tough economic patch, he's been using his illicit substance of choice a bit more heavily than usual.
- 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.
- The just-about-to-be-a-toddler baby doesn't help with the financial issues or the life frustration.
- His wife is not from this country, and thus has limited options as far as work goes.
- His wife's parents, living far away, do not particularly approve of him as far as we can tell.
- 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.
- 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.
- 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.
Wednesday, July 8, 2009
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.
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.
Tuesday, June 30, 2009
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.
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.
Monday, June 22, 2009
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".
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".
Wednesday, June 17, 2009
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.
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.
Monday, June 15, 2009
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:
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.
- Keep my widespread network of friends and family at least vaguely informed about what I'm doing and why I'm doing it.
- Provide me a place for introspection, feedback, and general thinking about the process of learning to care for the mentally ill.
- 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.
- 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.
Subscribe to:
Posts (Atom)