It’s nice to be wanted.
Active recruitment isn’t something physicians-in-training experience often, I think. (Maybe active recruitment isn’t something most people experience. I know no one was chasing me down when I looked for work in high school and college, though I was quite adept at clerical work and filing.)
Ali is applying to medical school, Graham and Brock’s wife are applying for residencies, and I will soon be zipping off for my fellowship interviews. (Clean suit? Check. Interview itineraries? Check. Plans to go dancing? Check. Social plans with friends? Check!)
I really do think that people work harder to recruit you the farther you are in your training. If that’s any consolation to anyone.
14 Sep 2007 | 2 comments.
Observations From Working Downtown:
>> Psychotic behavior in the indigent population is often adaptive. There are several reasons why people may exhibit psychotic behavior (where “psychotic behavior” means “talking to oneself”, “yelling at no one in particular”, “wearing five layers of clothes plus a wool hat on an 80-degree day”, “mumbling to oneself on the bus”, or other behaviors that are considered non-normative in this culture): Sometimes they are high on cocaine or methamphetamine; sometimes they have a chronic mental illness; sometimes they are medically ill and are undergoing acute brain failure. Sometimes people sustained brain damage from physical violence; sometimes they are “developmentally delayed” (formerly known as “mentally retarded”).
For women in particular, “psychotic behavior” protects them from assault. If they scream obscenities in an unpredictable fashion, men are less likely to approach them. If they lunge at passing cars and throw items at pedestrians, people will avoid them. If they dress in multiple layers and keep their hair shorn very short, they appear less attractive and thus receive less attention.
And when these women are tucked away in a cool room and chatting with another woman, they can and do behave within social norms. Though they may still share fears about alien uterus transplants and hidden cameras in the street lamps, they remain seated and exercise usual social graces.
>> Familiar faces appear in familiar haunts. While crossing the street, a man quickened his pace and peered at me from behind. I looked familiar to him and I knew we had met previously.
“Hi!” he greeted brightly. We crossed to the safety of the curb. “Do you still work at The Other Hospital?”
“No, I don’t,” I answered. “I’m sorry—you must remind me of your name—”
“Marcus,” he said. “Yeah, I remember you from The Other Hospital—”
—and then he provided a brief summary about his success in drug and alcohol treatment, his hopes to return to school, his activities within the church, and his intention to return to The Other Hospital to obtain ongoing care.
“That’s great,” I said, smiling at him. Sobriety had eluded him for many months and now, he was trying again. He flashed a grin at me—his teeth were misaligned and misshapen, but it was a warm smile nonetheless—and asked again, “So you don’t work at The Other Hospital anymore?”
“No,” I said. “I’m a resident, so I kinda go where they tell me to go.”
“Oh,” he answered. “Where do you work now?”
I pointed to a building down the street. “I work there now.”
“Oh!” he said again, this time with more energy. “I’ve been there before, too. Maybe I have an appointment there—I can’t remember. Oh well. Well, it was nice seeing you.”
We shook hands and waved farewell.
That was nice.
>> The opportunities for people-watching in the downtown corridor are endless. I attribute this to the sheer volume of people in the downtown district, though no other part of the city has as much diversity. Men in tailored suits and shiny cufflinks walk next to indigent men clutching overstuffed trash bags. Young women with large sunglasses and high heels clatter past delivery men carrying three boxes. Tourists with wrinkled maps pause next to janitors sweeping the entrance to the towers. Young hipsters with iPod buds in their ears swagger past young techy types in their pleated khaki shorts and polo shirts.
I catch glimpses of their lives and wonder who they are, where they are going, and what they want to do. They often look serious and driven—places to go, things to do.
And I wonder if I often look the same way.
>> What are the things we keep to ourselves? A woman spoke at length with me about herself. She was warm, friendly, and gracious. Life had provided her with a wealth of experiences—some painful, others not so much. And the more she spoke, the more her ideas spun into a world that wasn’t based in reality—the multiple ear and tongue transplants, the Asian women who followed her wherever she went, the deaths and resurrections of her three children.
But still so earnest and polite!
Had our conversation been short, had I forced our dialogue to remain superficial, had I not tacitly encouraged her to continue speaking, I doubt she would have shared these intimate—and delusional—thoughts with me.
We all keep things to ourselves, some things that we know may not make a lot of sense to anyone else. We learn to censor ourselves, though our thoughts may be diametrically opposed to our behaviors.
Behavior can often hint at thoughts and intentions, but is not always the transparent looking glass that we believe it to be. “We” are not that different from “them”, though we often wish that we were.
11 Sep 2007 | 2 comments.
Prescriptions for Alcohol.
The last time I had seen “beer” on someone’s medication list was during my third year of medical school. The patient was scheduled to receive one can of beer with each meal. The patient, a upper class fellow whose wife had curtly reported, “He drinks two highballs before dinner each night and a glass or two of wine with dinner—he’s not an alcoholic!”, underwent some sort of facial surgery. His surgical team wanted to prevent any alcohol withdrawal and hence ordered alcohol for him.
I found this rather odd at the time.
This time, I saw two alcoholic beverages on the patient’s medication list:
beer 1 application by mouth at each meal (1 application = 2 cans of beer)
vodka 60mL by mouth every four hours for tremors
“What?” I exclaimed out loud. “Vodka and beer?”
This man had also undergone facial surgery and reported at the time of admission that he regularly consumed large quantities of alcohol. To prevent withdrawal, the team prescribed alcohol. However, they also prescribed the CIWA-A protocol, which utilizes Ativan, a sedative used in preventing alcohol withdrawal.
“He’s getting alcohol and Ativan? What’s the point?” I further commented.
I scanned the sheet for further information: Overnight, he had received a total of 90mL of vodka (60mL at 10:30pm and 30mL at 4:15am). He had also received two cans of beer with breakfast.
I defied the urge to tip over in resignation.
When I spoke with the patient, I spied the can of Budweiser sitting next to the tray of mostly uneaten food. I picked up the can. It was empty.
“I’d like to stop drinking,” the man spontaneously said to me. “I’d save a ton of money if I didn’t drink anymore. Alcohol doesn’t help me with anything. Man.”
I asked the nurse about the alcohol. She smiled at me—the sort of smile you give when you’ve forfeited emotional investment—and shrugged her shoulders. “Yeah, we use it all the time on this unit.”
The primary medical team offered a succinct reply, “The surgeons worry that Ativan will interfere with their exam. They won’t let us prescribe it. They always use alcohol instead.”
“What?” I said. “What” was rapidly becoming the only word in my vocabulary.
After I explained my increasingly agitated rationale, the medical team remarked, “Yeah—you’re right. It doesn’t make a lot of sense, especially if he wants to stop. I guess we’re not really reinforcing a sound decision, are we.”
My mind boggled.
“What if,” I commented, “the local papers got a hold of this? ‘Hospital prescribes alcohol to alcoholics.’ This is absurd.”
Questions:
- Why beer and vodka? Why not just beer? Why not just vodka?
- Why choose vodka? What about rum? gin? whiskey?
- If we’re thinking about cost containment, why not just use malt liquor?
- Does the pharmacy purchase the alcohol? Which supplier do they use? How much do they order? How do they keep it in stock?
- How about boxes of wine?
- Who decides the dosing strategies? Why does “one application” mean two cans of beer?
- And why dose vodka at 60mL units? One shot is about 44mL.
- Is it easier to titrate volumes of alcohol rather than milligrams of medication?
- How does one justify that Ativan will interfere with an exam but alcohol won’t?
I can’t be the only one who finds this practice odd and disturbing. I cannot find any evidence to support this practice. To whom do I express my astonishment and umbrage?
9 Sep 2007 | 8 comments.
It’s Been a Long Week.
Recent working diagnoses I have given:
- psychosis, not otherwise specified (likely schizophrenia, though this technically cannot be diagnosed until six months of symptoms have elapsed)
- heroin dependence in remission
- social phobia
- obsessive compulsive disorder
Frequently played iTunes songs:
- Red-Eye (The Album Leaf)
- Headlock (Imogen Heap)
- You Didn’t Know Me When (Harry Connick, Jr.)
- Sunday Evening in Your Street (Ulrich Schnauss)
Recent purchases:
- Le Pens (by Marvy Uchida—a good pen, in my humble opinion) in seven different colors
- Mooncakes! (Mid-Autumn Festival is September 25th this year.)
- Salmon sushi rolls
- Four yellow nectarines
Things I considered writing about, but didn’t:
- The dogmatic creeds of psychotherapies that can make each school seem like a cult
- An open request for recommendations of good sandwich and cookie shops for my pending trip to New York City (the black and white cookie discussion is here)
- The surgery resident (I think he’s still a resident) who has no idea who I am, but who has nonetheless made a positive impact on the way I think about my identity as a physician
- The geographical spread of my friends (over the past week, I’ve spoken to people in Irvine, California; Sacramento, California; San Francisco, California; Chicago, Illinois; Philadelphia, Pennsylvania) and how that kinda sucks
7 Sep 2007 | 4 comments.
Bureaucrats Making Health Care Decisions, Part II.
This is why I am angry:
I evaluated a man in the emergency room. His wife, tired and stressed out, had brought him to the hospital for care.
They were both young twenty-somethings. They met in high school and started dating shortly thereafter. Following graduation, he conferred with her father and obtained his permission to ask for the young lady’s hand in marriage. She immediately squeaked yes! and less than a year later, they wed in holy matrimony. He worked in construction; she worked as a secretary. They were trying to save money to start a family. Neither one had health insurance.
The nurses told me that the man was unwell: “He’s really got problems.”
He was sitting on the gurney, his left hand over his left ear. A tired blue tee-shirt covered his stocky torso. He wore faded blue jeans that were a bit too long for his legs. Around his right wrist was a small, grey watch with a plastic band. He was probably four weeks overdue for a haircut. When he rubbed his right hand over his chin, the soft sound of his facial hair bristling against his skin crept out from underneath his stubby fingers.
After introducing myself and orienting them both to the interview, I asked, “What brings you to the emergency room?”
He looked up towards the ceiling, his lips muttering silent words. Both his wife and I watched him, waiting for his response.
His eyes eventually darted to my face and he simply replied, “I need to get this lump surgically removed from my chin.” He looked up again, muttered some more, and added, “God says it shouldn’t be there.”
I felt my heart sink.
“You have a lump on your chin?”
He looked up and silently mumbled something.
“Yes.”
“How long has it been there?”
More muttering. His gaze moved from the ceiling to my face.
“About nine weeks.”
He flattened his left palm against his ear and added, “It’s about the size of a cantaloupe now.”
I looked at his chin. Nothing about it resembled a cantaloupe.
The interview quietly unfolded. Things started to change about nine weeks ago. He learned that he was the Emperor of Microsoft. Satellites in space were tracking his movements through his cell phone and communicating with a worldwide network of Microsoft computers. The lump on his chin was alternatively a mark of royalty and a potential manifestation of infection. God had directed him to start building an ark and to take two types of all types of electronics on board.
He looked up again.
“I notice that you keep your left hand over your left ear. Why is that?” I asked.
“Satan is on my left,” he answered matter-of-factly—after conferring with the ceiling. “I can ignore him better if I cover my ear.”
His wife quietly picked at her fingernails.
When the interview with him drew to a close, he spontaneously commented, “I know I’m not acting the same way I did nine weeks ago.” He paused, looked up. “I can’t tell the difference between reality and fiction.” He paused again. “God tells me that this is the case.”
I nodded. He knew.
His wife then spoke in a hushed voice about his slow unravelling over the past few months. First were the references to God, then the consultations. His constant efforts to recruit other workers to help him build an ark resulted in his termination from construction. He started to barricade himself in the bathroom to test the water resistance of various materials. He turned on all the faucets in the apartment to flood the floors to model the ark that he had yet to build. Sometimes he declined to eat, as God would provide all the sustenance his body required.
“The mental health professionals have seen him three times,” she commented, referring to the sole agents in the state of Washington who have the power to involuntarily hospitalize people for psychiatric reasons. “They told me all three times that he’s unwell, but he’s not unwell enough. They said he hasn’t been a danger to himself or to anyone else, even with all the flooding and terrible things he’s said to his co-workers when they refused to help him build the ark.”
She sighed.
“He’s refused to see a doctor up until today. I don’t know what happened today—he was out walking along the waterfront—and when I asked him if he wanted to get help today, he said yes. This is why we’re here now.”
“God tells me that I’m not the same person I was. I think God is right. God likes doctors and wants you to help me today.”
I looked at him, completely uncertain what to say. However, we were all in agreement—a voluntary hospitalization seemed appropriate.
For patients who lack health insurance, one must obtain authorization from the county to voluntarily admit a patient to the hospital for psychiatric reasons. (This may also occur on other services, but I can guarantee you that no other resident or attending from those services is required to make these types of phone calls.) The screener gives authorization for the county to pass the bill from the hospitalization onto Medicaid to pay for services.
The screener asks a multitude of questions to the person who evaluated the patient to assess if the patient warrants hospitalization. Generally, patients are admitted if the clinical history supports that the patient is in imminent danger of hurting himself or someone else (where “imminence” is highly subjective and has little inter-rater reliability). Furthermore, if there is evidence that the patient has not adhered to treatment recommendations on “less restrictive” terms (e.g. outpatient care, follow-up appointments, etc.), this bolsters the case for inpatient treatment.
“I don’t see enough support to hospitalize this patient,” the screener told me. I’ve spoken to this particular screener before in the past and knew that he was sympathetic to my plea. “You haven’t told me anything that suggests that he is about to hurt himself or anyone else. However, I am going to consult with the supervising psychiatrist and get back to you.”
I waited. I was not optimistic. Yes, it was true: The patient wasn’t endorsing any suicide or homicide risks. The patient, however, was also remarkably disorganized: His (mis)perceptions of reality were directly affecting his behavior and, if no interventions occurred, his condition would only worsen.
This man and his wife were amenable to receiving help now to improve his function.
I didn’t pick up the phone on the first ring. I wasn’t hopeful.
“I cannot authorize this hospitalization,” the screener informed me. “Less restrictive options must be explored.”
When I shared this news with the patient and his wife, they both stared at me. She was shocked. His facial expression was completely blank—as is consistent with people who are psychotic.
“What?” the wife exclaimed. “Are you serious?”
Yes, I thought. Even though he’s psychotic, he’s not psychotic enough for hospitalization. Even though he’s flooded your apartment where electricity runs alive and free, he’s not unwell enough for acute intervention. Even though he’s barricaded himself in the bathroom and declined to eat due to dictums from the divine, he hasn’t harmed himself enough to warrant mental health care.
Yes—even though both the patient and his wife are requesting for help now, they cannot receive it because no one can pay for it.
Yes, only when he’s injured himself—only when there is documented proof that he has (inadvertently?) electrocuted himself or his wife—can he receive services. Only after he’s become so psychotic that he antagonizes other people to the point that they physically assault him is when he finally deserves care. Only after he’s stopped eating and drinking for a week and falls into delirium is he worthy enough to have money spent on him.
Never mind preventing morbidity or mortality as soon as possible. Let’s punish the people who are actively seeking care by withholding it from them because someone who has not evaluated the patient directly deems that they are not sick enough. Let’s only extend services to those people who may have nearly killed themselves or someone else.
Yes, I get it—everything has a price. We can’t just give free care to everyone. People argue about the costs of healthcare all the time. I get it.
What price are you putting on a human life? Are psychotic people worth less than people who are not? Does it really save any money to offer acute care to someone who is voluntarily asking for it in contrast to acute care that occurs after a potential fatality? Just what message are we communicating to people who have mental health conditions? That they’re not worth preventative care? That they’re just not worth it, period?
Is the investment of a voluntary psychiatric hospitalization—which also includes (1) establishment of health care benefits, (2) education and support resources, and (3) connection with outpatient mental health services to help prevent future hospitalizations—really unreasonable? What costs more: a voluntary psychiatric hospitalization or a medical hospitalization following a significant medical or surgical injury? (Think ICU, all the various nurses, physicians, ancillary staff, the supplies used for medical interventions….)
How can we withhold appropriate care from people who are appropriately requesting for help? Why are the opinions of evaluating physicians deemed inferior to those working for the financial establishment?
How can we as physicians ever expect our patients to trust us to provide appropriate care for them when we are essentially limited in our abilities to offer appropriate interventions?
How is this okay?
This story has a happy ending. I conferred with an attending who, in his wisdom, helped me to reframe the above arguments. I contacted the screener’s supervising psychiatrist and appealed the decision. I was able to obtain authorization for the hospitalization. We were all relieved.
“Thank you,” the wife gushed, the relief apparent in her face and body. She extended her hand, eagerly grasped mine, and shook it vigorously.
After looking up and recupping his hand over his ear, the patient said, “Thank you. God thinks this is the right decision.”
4 Sep 2007 | 14 comments.