Guns Scare Me

A few weeks ago, I was called to the ER to see a man who had threatened to kill another man in a drunken rage. When I spoke to the ER doctor over the phone about the case before actually seeing the patient, my first question was, does he have any weapons on him? And if you haven't asked, could you go ask? He had a 3 inch knife on him (legal to carry in the hospital if it can't be opened with just one hand), but no guns. 

Then, a few nights ago, I was called to evaluate another man in the ER. Halfway through the conversation, he started talking about a shooting at another hospital. I am not sure how he got onto the topic or what his point was (something about saving extra medicine at home in case of an emergency), but I became anxious. He sat with a large black bag on his lap, and I knew he had some other belongings out in the waiting room. What if he had a gun in that bag?  I could not focus on what he was saying anymore. My rational mind told me that this man was at quite low risk for acting violently in the next few minutes. He had no history of violence, he was quite cooperative and friendly while I interviewed him, and he was not intoxicated. But I couldn't focus. What if something happened and I had ignored my feelings? My heart was racing. My patient's lips were moving, but all I could hear were thoughts in my own mind. I knew I needed to take a break before going any further. I abruptly stood up and excused myself from the room. I had to get out of there. 

I ducked into the social worker's office across the hall and confessed to her why I had stopped the interview. I felt really silly. This person probably didn't have a gun, but my imagination, with recent current events for material, was running wild with possibilities.

I called the grounds security police to accompany me back into the room. I thought there might be a "safe" way to ask this question, but there really isn't. The police man looked at me, then looked back at my patient and literally said, "Sir, do you have any weapons on you?" I had been scared to ask that question on my own. 

Like the patient I mentioned first, this man also had a small blade on him, but no guns. He was embarrassed; he thought that I had seen the knife he kept on his belt and then called the police in because of that. He quickly unbuckled his belt, on which the knife pouch was threaded, and reached behind his jacket to pull it through the loops. This motion made the policeman say, "Hey! Hey, what are you doing?" My patient immediately put his hands up in the air. "I'm sorry," he said. Now it was awkward, and we were all on edge for apparently no reason. I thanked the officer for his help, and then I was back with my patient, finally talking about what brought him to the ER in the first place. 

Recently, I have felt extemely vulnerable when meeting patients for the first time in the emergency room. People come in from a number of different situations from the community. They are not initially screened for weapons, and though a sign at the hospital entrance prohibits weapons, I'm not sure what deterring power it has. 

There has been extensive press about mentally ill people and guns in the context of horrific recent shootings. There has been a push to prevent mentally ill people from getting their hands on guns. In California, the law prohibits anyone who has been placed on a 5150 hold from owning or buying a gun for 5 years. However, enforcement is problematic, and as we have seen recently, people get access to guns from family members and friends. 

To work under the knowledge that people can be carrying weapons freely and/or illegally is unsettling to say the least. At times, I am finding it makes it difficult to focus on my job and to treat people openly and without fear. The more I learn about people, the more I realize we can't control people. But we can control  the weapons that are acquired by citizens and what ammunition is out there. Let me get back to my job. Let school teachers get back to their jobs. Let movie and mall goers enjoy themselves with peace of mind.  Gun control is what our administration should focus on. Obviously there are a lot of nuances here, but in the clinical setting, my recent personal reactions have been quite strong and clear, however rational or irrational they may be.

   

Not-so-great expectations

I am really tired from over four months of inpatient work. The time requirements of being an intern have meant that I have had little time to maintain aspects of my life that used to define me. When friends or family ask to hear what I've been up to, the answer is work. When applicants to the psychiatry program ask me what my hobbies are, I tell them what I used to do. Though I know this is a very unique and all-consuming time in my training, it is still disturbing for my identity to be reduced to my job and to often be isolated from the healthy majority of people.

On one hand, I love being a doctor. I love working with people and often helping them. I love learning and becoming skillful in different areas. But for all of this, I also resent what I have to sacrifice in order to do these things. My own ability to cope with stress, with sick patients, with anxious families, with abrupt co-workers, is reduced in my state of physical tired-ness and shallow emotional reserve. At my best, I can take things in stride, give myself and others a break, and go home and get a good night's sleep. At my worst, I've taken out my frustrations on family, friends, co-workers, and even subtly on my patients.

One of my mentors told me that the key to maintaining reserve is to offer oneself unconditionally without being invested in the outcome. In other words, give freely, with no expectations of anything in return. So I shouldn't expect patients to agree with a plan I have thoughtfully put together. So I shouldn't expect patients to thank me for going out of my way to make appointments for them. So I shouldn't expect patients to miraculously change their lives because I treated them. Sounds obvious (and I sound narcissistic) writing this, but sometimes, I get the idea that when I spend time and energy on something, that I should get something back in return! Credit, gratitude, a break, kind words...and it just doesn't work that way. It's a weird dynamic between being taught that we are "worth" this and "deserve" that and "our time is valuable"--but do these ideas fall into the categories of self-respect, self-preservation, self-defense or self-righteousness? It's not always clear. By freely giving (and also by asking for what we need in earnest), we can tap into an endless supply of love and energy to share with people.

Basic Mental Health Law

Last month, I went to court. The proceeding was held in a conference room on my hospital unit. In front of a county judge, I stated that my patient should continue to be hospitalized against his will because of his high suicide risk. The evidence to hold him included: a recent suicide attempt, past suicide attempts, recent end-of-life gestures including saying goodbye to his son, and constant thoughts of killing himself. 

The patient, who wished to leave the hospital, sat across from me. An appointed lawyer, a mental health specialist, spoke on his behalf. She appealed for his discharge, stating that he would continue outpatient psychiatric care and that he was making future-oriented decisions such as establishing his social security benefits. 

Mental health law is different in each state, but in California, the rights of mentally ill patients are currently protected under the Lanterman-Petris-Short Act (LPS), which was signed by Governor Ronald Reagan in 1967. Some of the wording includes, "to end inappropriate, indefinite, and involuntary commitment of mentally disordered persons..., to provide prompt evaluation and treatment of persons with serious mental disorders..., and to protect mentally disordered persons and developmentally disabled persons from criminal acts..."

Under LPS law, patients must meet one of three criteria to be held against their will: danger to self (DTS), danger to others (DTO), or grave disability (GD), which is one's inability to provide a plan to get food, clothing, shelter.  Importantly, the criteria must be true because of a mental illness, and not a medical illness (like dementia or brain tumor) or criminal pursuit. 

Out in the community, police or designated mental health workers can place what is called a 5150 and bring a person to a hospital for evaluation. A 5150 is valid for 72 hours and cannot be contested by the patient, though it can be discontinued earlier than 72 hours a doctor. At the end of 72 hours, if a person still meets DTS, DTO, or GD criteria, a doctor can apply for a second certification that allows a patient to be held for an additional 14 days. This is called a 5250, and this CAN be appealed by patients. They have the right to see a judge within three days. 

While it may seem that LPS law imposes on more rights than not, the law ensures prompt evaluation by a doctor and continual necessity for justifying hospitalization, which is in contrast to the old days when mentally ill patients were held indefinitely against their will and subjected to treatments without consent. In addition,  mentally ill patients have other protections against forced treatment. Under LPS law, even if patients are held, they cannot be given routine medications against their will (this requires another court proceding). To administer any medications on a psychiatric ward that affect a person's brain, the patient must given documented consent. Interestingly, these same medications, if prescribed in a general medical clinic or on a surgical ward, would NOT require consent. 

To finish my story, the judge denied my patient's appeal, and his hospitalization was continued against his will. While I do think we were protecting him from self-harm and buying time to help his depression, it made my relationship with my patient adversarial. It felt contradictory to testify against him one afternoon and then invite his trust the next morning in our daily sessions. It was quite uncomfortable and challenging to rebuild that alliance with patient in the following week. It also infused questions into my mind if we are doing the right thing by holding the patient and reminded me of the seriousness of taking away someone's civil rights. 

The Making of a Mind

Hello again, world! I haven't posted in about three years to the date. According to that post, I was considering many different medical specialities. Looking back, I didn't mention psychiatry! And now I am more than half way through my psychiatry internship (first year of residency) at Stanford.

Psychiatry is a medical speciality that treats illness of the mind and brain. Patients might have symptoms in the areas of mood and emotions, behavior, thinking processes, perception, sleep, or language. 

Understanding psychiatry means understanding the layers we all have. As new creatures, we start out with brains that are wired a certain way. We have certain genes, which gives us certain anatomical wiring and neurotransmitters, which, in turn,  makes us more or less likely to be depressed or anxious or even have hallucinations. Now take this pre-made device out of the womb and expose it to the world. The young brain is incredibly dynamic and reactive to its surroundings, and it grows and adapts. This learning results in behavior. We get older and our brain stops changing so quickly, but it continues to change throughout out our lives.  If we are lucky, we start out with a good piece of equipment, are nurtured, loved, encouraged, face just the right amount of hardship to produce growth, but not be traumatized, avoid toxic substances, and attend a stimulating school, and so on. This whole picture, with all the layering, refers to someone's mental health. 

Another way to think about it: just as some of us have bad knees, are prone to colds, or have poor eyesight, some of us started out with wiring that is slightly different. Then, just as too much running on pavement might lead to stress fracture for some people, so might psychological trauma or stress lead to depression, PTSD, or substance use.  We can often get through a cold or a sore knee on our own, and similarly, we can often get through some depression, anxiety, and even substance use on our own.  But sometimes we need a doctor. 

Another angle that I sometimes use to think about mental illness is whether or not someone can be "talked" out of an unwell state. By that I mean, will someone respond to therapy, which would indicate that he or she is able to harness and train his/her mind. This requires a certain amount of insight and ability to step outside of one's mind and examine oneself objectively. On the other hand, some patients have illnesses that may improve a little bit with therapy, but ultimately require medical intervention, and maybe even hospitalization, for treatment. These people might have severe depression, schizophrenia, or dementia. Of course this model is oversimplified, but I think it is helpful way of thinking about the components of mental illness and how they interact and overlay.

Doctors of mental illness come in two varieties: psychologists and psychiatrists. In traditional comparisons, psychologists address behavioral or learned aspects of mental health, while psychiatrists use a medical model of disease to diagnose and treat mental illness. Psychologists use various types of therapy as their main tool.  Psychiatrists receive broader training that covers some general medicine and neurology as well, but receive less depth of training in therapy and behavioral science than psychologists. The toolbox of a psychiatrist includes therapy, medications, and even procedures such as electroconvulsive therapy and magnetic stimulation. 

The psychiatrist is also trained to help other doctors determine whether a patient has a primary psychiatric disorder or whether an underlying medical condition might be responsible for psychiatric symptoms. In particular, many neurologic disorders are accompanied by or mimicked by psychiatric disorders. Patients with parkinson's disease may have hallucinations. Patients with multiple sclerosis may experience depression and decreased cognitive function. Personality change might be the first symptom of a brain tumor. Also, patients might have neurologic symptoms such as twitches or seizures that are actually psychiatric in nature. Chronic pain is another entity that can be approached from a psychiatric perspective.

So there are a few ways to understand psychiatry and a few reasons why I think it's a great field. My final thought for the night is that I love that the marker of success in psychiatry is improvement in a patient's ability to do the things that make us human-- like feel, think, and love-- and to participate in meaningful activities such as work and family life.