Thursday, January 2, 2014

Five Little Monkeys

First: Happy New Year, readers! I can't believe how quickly the time flies. Reward yourself by doing something amazing this year!

Somewhere, my son recently learned the classic children's song, "Five Little Monkeys". He was singing it rambunctiously a few nights ago as he threw himself around on my bed:

Five little monkeys jumping on a bed One fell off and bumped his head Mama called the doctor and the doctor said "No more monkeys jumping on the bed!"

As we all know, Mama was unsuccessful in keeping the monkeys from jumping on the bed, they kept falling off and hitting their heads.

As my son worked his way through all those monkeys, it struck me (pun intended) that I really liked the doctor portrayed in this song. I imagined that when Mama called the doctor, he might also have said, "Here's a prescription for Norco!" or "Bring him in for an MRI!" Aside from the fact that those wouldn't rhyme, those wouldn't address the root of the problem. So often in the practice of medicine these days, doctors (including myself) end up (for a variety of reasons) focusing on patching up symptoms instead of getting to the bottom of them.

In my mind's eye, I picture an elderly silverback gorilla wearing a white lab coat and a stethescope around his neck. He answers the old rotary phone on his antique desk, closing his eyes for a brief moment as he listens patiently to Mama's latest story of monkey shenanigans. Should she take him to the emergency department? Can she get a prescription called in for him? He takes a slow, deep breath in and calmly explains that her dear monkey will be just fine, just fine, but that one of these days, there might truly be a serious injury. What really needs to happen, more than anything, is to set firm boundaries about jumping on the bed.

We all need to learn to keep our monkeys off of our beds. Roughly 7 of every 10 deaths in the United States is due to a chronic medical illness, and abundant research points to lifestyle interventions- making positive, healthy decisions to improve our wellbeing- are the best treatments. Eating better, exercising more, quitting smoking, not drinking alcohol excessively, getting a good night's rest- that is what we need to do in order to feel better. It has been said many times, that if all the benefits of exercise could be obtained by taking a pill, everyone would be on it. The monkeys may need to stop jumping on the bed, but we need to start.

This new year, don't make a burdensome weight loss resolution. Instead, make a commitment to yourself to be healthy. That's it. Find an activity you enjoy, that gets your heart pumping, and do it, for at least 20 minutes. Enjoy the endorphins flooding your veins. Instead of chowing down on a greasy meal that leaves you feeling bloated, reach for a healthy snack, something fresh with a crunch to it. Put down the cigarette- as hard as that can be. Find a friend who also wants to quit, so you can do it together. Talk to your doctor about how to get healthy- you might surprise yourself about how many of the medications you're on, that you can stop taking once you put these principles in place. Sound like fun? Give it a go! And whatever you do, take some time to learn from kids. They have a lot to teach us ;)

Wednesday, July 31, 2013

The Chicken Soup Element

This post is dedicated to my Grandma Sue, who is so patient with the long periods of time where I neglect to keep in touch with her.

I have been thinking a lot about the importance of the concept of family lately. My mother-in-law wasn't feeling well yesterday, so after work I headed over to her house with a tupperware of soup my wife had made. I texted my best friend and let him know what I was up to, and he made a comment about how nice a thing that was. My response was, "What are family's for?" and then I really started thinking about all the situations I've had in the last few weeks where I have sharply noticed the importance of family.

I am in the middle of my 6th week now as a resident psychiatrist at my county's mental health facility (apparently we can't technically call it a psychiatric "hospital" for some bureaucratic reasons, but that's essentially what it is). During my time so far, I have really come to see how important families are for the patients who come through here, and the devastating consequences that come when someone either doesn't have any close family or they are no longer involved, for whatever reason. In my first week, I met a young Hmong man in his first presentation of schizophrenia, who had been found on the edge of a bridge, experiencing voices in his head telling him to jump off. I remember meeting his family for the first time- he had gone missing days earlier, and his mother had no idea where he was or if he was even still alive. When his symptoms had improved to the point where he was able to be discharged, his family welcomed him home, with a strong plan in place to help him make sure he received the care he needed.

As encouraging as it is to see people rallying around their family member in need, unfortunately I have seen the opposite end of the spectrum much more often. Much too frequently, I have seen people depressed to the point of contemplating or even attempting to take their own lives, and there are no family members who are around to support them. I recently called the family member of a young patient on the unit who likely has schizophrenia, and when she answered, she said, "She's always getting herself into trouble. I don't want to deal with it anymore", and hung up. As understandable as those sentiments can be, it leaves me in a situation of trying to arrange a homeless shelter for this person, when her symptoms are sufficiently treated that I can no longer keep her against her will. Similarly, consider another man I recently cared for, who has dealt with psychotic illness and drug dependence for decades, and at this point his intellectual function has declined to the point where he hardly knows where activities of day to day living are nearly impossible for him to do on his own. Before he came to our treatment center, he had fallen in with a woman who convinced him to sign over his disability check to her, and was making him live in a slovenly house and barely providing food to keep him alive, before he escaped and walked into an emergency room. I'm sure he "burned his bridges" long ago, but it's difficult to think that, if he'd had some family involvement, he never would have ended up in that sort of situation. The best we could do for him, after redirecting his disability check and filing an Adult Protective Services report, was link him up with a reputable Board & Care facility.

I'm not saying that only people who have a certain percentage of genes in common are able to help care for each other. I have had the privilege to work with so many physicians, clinicians, and other health care workers who are incredibly compassionate; alternatively, I have certainly come across family members who only seem to exacerbate existing problems. But overall, there is something unique and powerful about the relationship between family members. They just bring something special to the table- call it the chicken soup element, if you will. To all you people out there who have loved ones struggling with illness, whether mental or physical, kudos to you. You are an irreplaceable element of their care, even though your contribution often goes unnoticed and underappreciated in the background. Power on, and make sure to take some time for your own wellness, too!

Sunday, December 30, 2012

2012 Reflections: Psychiatry

The year 2012 is coming to an end. It has been a long year, full of joy and discovery, as well as grief and tragedy. Personally notable for this year is that I received my M.D. and began training in a combined family medicine and psychiatry residency program. It has been such an amazing mass of experiences thus far, and it's only just beginning. In this post, I aim to discuss why I feel it is such a fascinating time to be a young psychiatrist.

The field of psychiatry is developing at a breakneck pace. Great strides have been made since the mainly psychoanalytic era of the 1950s, with a much better understanding of the causes of mental illnesses, and the discovery of medications that can help treat them. Schizophrenia is an excellent example of the progress being made. Though there remains much still to be learned about the disorder, many of the dysfunctional neural pathways have been identified, multiple genes associated with its development have been discovered, and a host of very effective medications exist. Similar strides have been made with a variety of other mental illnesses, including major depression, bipolar disorder and PTSD.

As our understanding of mental illness has improved, a need for better conceptualization and classification has arisen. This is reflected in the much anticipated release of the new DSM-V in May of 2013. The DSM, or "Diagnostic and Statistical Manual of Mental Disorders" is the primary book used by psychiatrists to diagnose and classify mental illness. There has not been a full revision of the DSM since the release of the DSM-IV in 1994, though there was an update (DSM-IV-TR or "text revision") made in the year 2000. Work on the DSM-V began in 2010 and many steps have been taken to incorporate the last information on mental illness into its pages. I am thrilled to be in my residency during this exciting transitional period.

Despite these advances, there is a lot that still needs to be done. Why is there still so much untreated or undertreated mental illness? Much of it has to do with stigma. Even though we know so much about the genetic and biologic causes of mental illness, there are many who still think of it as being under the control of the sufferer. I daresay that many people think that those suffering from mental illness just need to "man up" or "cut it out" or "just get over it", though we would recoil in horror if someone used similar language to a person with cancer.

An abhorrent extension of this stigmatization is the so-called "mental health carveout" with health insurance. In many cases, psychiatric treatment is specifically written out of insurance policies. What about the countless mentally ill without health insurance? They fall back upon government funded institutions, whose severely limited funding has even further plummeted in recent years. The single county-funded mental hospital in my city recently had to shut down function of half of more than half its beds because of lack of funding. Gravely disabled patients and those suicidal or homicidal from mental illness sit in the city's emergency rooms for days waiting for placement. It's been a rare day for there to be an empty bed when I've worked on the psychiatric unit of the county jail.

All in all, I'm extremely excited about becoming a psychiatrist. We've learned so much and are continuing to expand our knowledge of mental illness and its treatment. There is so much still to be done in terms of decreasing the stigma and marginalization of mental illness as a weak will or deficiency of character, and so much work to be done in terms of increasing access to care to those who need it so desperately. I'm thrilled to be in the thick of it.

Monday, August 13, 2012

Fragmentation

As I was driving to work this morning, I was thinking about how I wish I had time to exercise more. It's my 7th week as an intern, and I have only gone on a run once in that time (a 2.5 mile run last week in 25:30- pitiful considering that two months ago I was running 8-10 miles at least once a week). I got to thinking about all the patients I have to whom I recommend exercise (an almost literal panacea in terms of health benefits), but tell me they just don't have time for it. How did it come to be that we don't have time for exercise? What's with the explosion in obesity, and particularly childhood obesity?

Then the realization hit me, that all our modern conveniences have created a new way of life where we actually have to schedule time for things like exercise, when it used to be just a part of everyday life. I'm driving to work in my pickup, but people used to have to walk- even if you had a horse to ride, that still took a fair amount of physical effort! So much of our "work" these days is mental, and our bodies suffer as we sit at a computer desk all day long, day after day- something new research shows is devastating to your body, even IF you hit the gym on your way home from work! For most of us, gone are the days of plowing and digging, building your house by hand, picking your own food, and coming up with your own entertainment rather than sitting in front of a screen being passively entertained.

I think our lives have lost a lot of richness due to this fragmentation of our lives. "Exercise" didn't used to be its own entity, because your day was packed with physical activity, from your morning chores, to working in the fields, to walking wherever you had to go, running and swimming and hiking and fishing as a carefree child and dancing the night away because there was no TV to squat in front of all night. Now "exercise" is a dreaded event which must be planned into our schedule, which we usually engage in alone, with only our iPod to keep us company.

Our consumption of food has been divorced from the simple joys of sowing, harvesting and preparing it. We feel hunger, look for the nearest golden arches and load up. Where is the investment? With such easy availability, no wonder we are adding up the pounds. To eat, you used to have to pick it yourself. Pound out the wheat yourself, knead the dough yourself, bake it, mix it...and now it's as simple as "A #1 please!"

The examples abound, of our modern technology making things yes, more convenient, but also robbing us of the joy of the process. Emails are much simpler to send, but where is the joy of carefully planning and penning a thoughtful letter- or receiving one? A text message is convenient to send, but what about sitting down to a cup of tea (or coffee) with your friend? It doesn't get more convenient than television, but what about sitting on the porch, talking about life and watching the kids run around in the yard.

I'm not against technology or our modern advances- to be sure, I probably use them as much or more than the average American. But I can't help but mourn the price that such technology comes with- a fast paced, "convenient" but empty life. Aren't you tired of going through the motions? Make a commitment with me to try to escape the monotonous routine, and take back some of the richness that life can offer. It may not be efficient to stop and smell the roses, but it's essential to a rich life.

Wednesday, June 27, 2012

My First Few Days

I started my internship on Monday. Let me just tell you, I am absolutely loving it. There are so many wonderful aspects to my job, and while I will admit that I'm a bit tired as I write this, I am so thrilled to finally be a doctor. Some of the best things about what I get to do:

>>The patients, both in the hospital and out. I am so honored to be able to care for people in some of their most vulnerable moments. In my current rotation, I am caring for patients with general medical problems in the hospital, and I also have clinic in the afternoon one day a week. I am already seeing such a variety of people, with their diverse personalities and ways of dealing with illness. Yesterday was my first day of clinic, and it was so exciting to actually be seeing people that I am now the primary care physician for. Some of the problems I saw were able to be treated with one visit alone, but one person I saw will be following up with me in two weeks. It is such a rush to be able to schedule someone to follow up with me! It's one of the things I love about family medicine- being able to build relationships with people over time, and take a step by step approach in helping them out.

>>The staff here. Everyone is so good at what they do! I'll admit that my pager has a way of going off every time I finally get to sit down for a second, but the nurses here are exceptional. They are extremely competent and very friendly. The same can be said for the rest of the staff, from program coordinators to discharge planners to pharmacists. It's really a pleasure to work with everyone.

>>My fellow residents. What an awesome group of doctors I get to work with! It is so refreshing to find doctors who are passionate and enthusiastic about what they do. The attending physicians eager to teach, my senior residents have been so helpful, encouraging and patient with all the things I don't know how to do yet ("Is this how you order an ultrasound?"; "Where's the interventional radiology lab?"), and my fellow intern class is really a solid group of doctors. Coming to work is a blast with such great people to work with! It's a privilege to be a part of both the family medicine department and the psychiatry department, because I get to work directly with twice as many incredible people, and both departments have really made me feel at home. The first two weeks of orientation there were so many "Welcome Intern" events that I couldn't even go to all of them!

It's so great to be able to work hard in the hospital and play hard with my kids when I get home. The new work hour restrictions laws only allow interns to be in the hospital for 16 hours at a time, so I'm getting a fair amount of time with my family when I get home, too. After clinic yesterday I went home and took my kids to the swimming pool and spent the rest of the night watching "LOST" with my wife. Granted, I'm on an easier rotation right now, and I'll be a fair bit busier during the two ICU rotations I have next, but I'm not worried about it. I love my job and have a great support system both in the hospital and at home. Life is good :)

Tuesday, June 19, 2012

Global Philosophies on Justice

A few weeks ago, I received my rotation calendar for my intern year. Every three months for the next two years, I will switch back and forth between family medicine and psychiatry rotations, since I am in a program to become board certified in both of these specialties. Anyway, I noticed that in December of this year I will be doing a month of psychiatry at our county jail. In this rotation and others in "forensic psychiatry", as it is known, I will perform psychiatric evaluations of inmates, be a member of the "expert witness" team at trials and propose/implement treatment plans for inmates with mental illness.

I think that my impending up-close involvement in the justice system is one reason that I have lately become more attentive to the system as a whole. One article in CNN today caught my eye for this reason(click here to view). The article highlights the looming implementation of a recently passed law in South Korea which allows the "chemical castration" of convicted serial rapists. At first, I was put off by this notion, but I find that my opinions are changing the more I think about it.

I wish to clarify that in tentatively supporting this idea, I am decidedly not echoing the boorish rants in the comments section below that article. Those comments, crassly suggesting that a serial rapist "deserves" only physical castration, exemplify the very American justice philosophy of revenge. From what I have noticed, the American justice system seems to place a large emphasis on punishment, and the general public seems to think that even the harsh prison sentences and the executions that still do happen in the U.S. are not severe enough to sufficiently punish inmates for their crimes.

In contrast, the South Korean law seems to actually be an attempt to decrease the risk of repeat offense. "Chemical castration", as the article describes it, involves a mandatory injection of some compound (I won't speculate here what the compound might be) which would theoretically decrease the sex drive of the convict, but that is all. Those sentenced under this law would stay under close scrutiny for three years and receive treatment for up to 15 years. As I think about it, in the United States we already use antipsychotic or sedative medications for violent inmates even if they do not consent to treatment. Are sexual offenses all that different? I haven't thoroughly thought through the potential implications of such a move, but it doesn't seem like an unethical leap.

And after all, shouldn't our focus as a society be on rehabilitating criminals with intent to reintegrate them into the fabric of our society, rather than retaining our current system which encourages repeat offenders and establishes a rather large population of citizens who cycle in and out of prison for life? To take an extreme example of a rehabilitation-based system, consider the example of Norway. Last month, I was reading this article about the "World's nicest prison", located on an island off the coast of Norway. I encourage you to read the well-written, if lengthy, composition. It details the Norwegian judicial philosophy, including their short prison sentences and emphasis on teaching convicts how to return as productive members of society, and providing those opportunities.

Such a system doesn't leave the vengeful with much satisfaction, but I ask you to consider, should our focus be on making ourselves feel better about the proper retaliation against an offense, or should our focus rather be on reducing the "recidivism" rate, or risk of repeat offense after a criminal is released? Say what you will about the Norwegian system, the numbers don't lie. The Norwegian recidivism rate at 3 years out is 16-20%. In the U.S.? It's 43-50%. Food for thought.

NOTE: I greatly appreciates responses/discussion, but please keep it civil. Thank you.

Saturday, June 16, 2012

So, I'm a Doctor

A lot has happened since my last blog post. A LOT. My wife, our two kids, two dogs and I have moved cross country in an F-150 pulling a camper trailer full of belongings to our new home in our old hometown. We decided to rent a two bedroom apartment for the first 8 months or so, so we could find a home to buy that we are truly thrilled about and not rushed into. We've been out here for just over a month now, insanely busy but loving every day in the Golden State.

The first few weeks were primarily related to getting settled in to our new apartment. The hustle and bustle of acquiring furniture, unpacking boxes and deciding where everything should go filled our days. Then, last Sunday, I officially became a doctor. I wasn't able to make it all the way back to Ohio for the ceremony, but the graduation for the Class of 2012 came and went, leaving me with the coveted letters of M.D. to place at the end of my name.

Then, this Tuesday, it all started to become intensely real. Every day since has been crammed with orientation, paperwork and meeting people. Most of my orientation events have been with the Family Medicine department of the medical center, since they start a bit earlier than the Psychiatry department. I cannot begin to express how excited I am to be working with these incredible people- the staff all seem to be incredibly organized, efficient and thoughtful, the program directors and faculty seem to be involved and friendly, the "older" residents all seem excited about us joining, and I think my entire intern class is really a solid group of doctors.

Our wonderful Family Medicine department realizes how important it is for the interns to all get to know each other, so they sent us all for a half day at a team building adventure camp. What fun! We learned a lot about each other, and most importantly have learned that we can trust each other, which will be invaluable starting on the 25th, when we actually begin working in the hospital.

Also exciting has been the two days we spent getting certified in resuscitation. We spent one day on "neonatal resuscitation", meaning what to do when a baby is first born and isn't doing so well. There was a sophisticated infant mannequin that would cry, wiggle, turn blue and breath, depending on how well we were doing. Our team really knew its stuff! The following day was adult resuscitation, from BLS (Basic Life Survey) to ACLS (Advanced Cardiac Life Support). Basically, it's the steps of what we all do as a team when a "Code Blue" is called in this hospital. There are a lot of steps involved! But at the end of the 8 hour day, we all passed our "Megacode" simulation test and got certified.

The rest of our time has been filled with equally important but less thrilling events like training on our electronic medical record (really top of the line), and filling out page after page of paperwork. Next week we will get orientation more specifically to what we will be doing in the hospital (and learning our way around it), meet with our faculty mentors to discuss our specific goals and interests, and wind down the week with a pool party for all residents, faculty and families before the big day on June 25. Everyone try to stay safe and out of the hospital for a few weeks while we figure out what we're doing, ok? :)