Of guns

Newtown is half an hour away from here. When the shooting at Sandy Hook happened, I was at work. I could hear the clinicians talking about it in the hallway, and I started to Google for news. The details kept coming in. When it became overwhelming, I got off the internet, because I had patients to see. A lot of them, especially the parents, came in tears. I had to listen to them, stay with them in that moment, and be honest about my inability to offer much more than support.

It kept eating at me, though. The news on the local radio. The way the classic rock channel that I like (owned by a conservative corporation) went from saying “It’s too soon to talk about guns” to calling the President Loser of the Week for wanting to enact gun safety reform. When the opportunity to volunteer in Newtown came, I jumped at it. It gave me a chance to feel like I was doing something, even if most of it was sitting around in a school, chatting with middle aged counselors from nearby towns, more mental health professionals and therapy dogs than people who needed them in the cold evening hours.

I have an alien’s perspective on guns. India is not a hunting society. I grew up vegetarian, in a religion where any form of violence, even a mental “I want to strangle him!” is a sin. A significant part of my childhood was spent “rescuing” pests- ants, cockroaches, wasps- and releasing them outside rather than killing them. I never saw a gun until I was 13.

That’s when it changed. My father, a well-to-do businessman in a small town in a state that is considered The Wild West of India, was kidnapped. This wasn’t unheard of in election times. It was business as usual. They wanted money. The policemen came. There were long meetings that I wasn’t a part of. Policemen with guns sat around our house and the maid took them tea and biscuits. Four days later, my father came back.

The next day, a senior police officer told my father to buy a gun. He smiled at this, but applied for a license just the same. A month or so later, I saw my first double barreled musket up close. I could never imagine my father shooting at someone. Neither could he, and in a few days, the gun disappeared somewhere in my mother’s pantry. We never saw any bullets.

The next time I thought about a gun was when I took this job. One day a week, I was working in a substance abuse residential facility, the patient population mostly made up of felons under court mandated treatment. Some of them were sociopaths. They tried to charm me into giving them a diagnosis that would lead to secure housing. When that didn’t work, they would try aggression. There would be pointed questions, about my car that was parked outside, my family, where I lived. They would talk about violence, about what they might do if they didn’t get the help they needed.

There were days I got scared. There were days I frantically looked up scales that would tell me the likelihood that they would attack me, what I could do to make sure they didn’t. I didn’t find much beyond what I already knew. I thought about buying a gun. Another few minutes of research told me that that was stupid, that I was more likely to be killed by my own gun than to be able to defend myself with it. So I didn’t.

Instead, I turned to my father and his faith. The good old hota swayam jagat parinaam- The World Takes Care of Itself. I will die some day, and I don’t control how/when. I will not be stupid. I will not own weapons that are likely to kill me/my loved ones/or even complete strangers. Children. Innocents. I will volunteer at all the Newtowns where I can. Because I know there will be others. As long as there will be guns.

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Election 2012

I read two articles in the newspapers today, one about Governor Romney’s 2011 tax returns and the other about a welfare mother. (Remaining cognizant of the fact that this is the NYT, a newspaper with a liberal bent.)

It made me think about my role in this society. I am a legal alien. I came to this country as a student and went through specialized psychiatric training. I invested a huge amount of my own money to start the process and was then paid a salary by my training programs, in return for the patient care I provided as a trainee. By general consensus, medical trainees provide a lot more skilled labor than they are paid for. While training as a specialist, I worked 80 hours a week, took overnight calls taking care of extremely sick patients, and made anywhere between 30,000-50,000 dollars a year throughout my 5 year training.

At the end of this training period, my agreement with both US and Indian governments was to return to my country. But like most skilled immigrants, I wanted to stay. The US government allows me to do that if I promise to serve in an under-served area with a health professional shortage, for a minimum of three years. Before hiring me, a health organization has to prove that they advertized for an American citizen to take the job for at least 6 months, and no one did. I took one such job.

I now work for a Federally Qualified Health Center in an inner city area. All my patients are poor, most of them have Medicaid, with a small proportion being on Medicare and private insurances. I also see patients who do not qualify for Medicaid yet can’t afford private insurance- the center puts them on a sliding fee scale, and they are able to see me and their other doctors at about $20/visit. This adds up when you add the cost of paying for medication out of pocket, but thankfully, the 4 dollar drug programs from companies like WalMart allows me to make sure they have the bare bones medications they need.

What does this mean for me? Most days, my practice feels like trying to plug a hole in a dam with my finger. A vast majority of my patients have been too sick to work for years. This includes those with schizophrenia, those with severe bipolar, crippling depression, dementia, traumatic brain injuries, moderate-severe mental retardation.

Some people who come to see me have milder symptoms. Often, they bring in disability papers for me to sign. Sometimes, I have to tell them that, in my opinion, their mental health diagnosis is not enough to keep them from working. A lot of these people drop out of treatment when I tell them that. Some don’t.

Most of my patients live in a continual state of crisis. They don’t have transportation, or housing, or food, or money for their children’s school supplies, money to take their family to doctors who don’t accept Medicaid. I try to see them often, because every month brings a new crisis. “I lost my visiting nurse because the insurance said I no longer qualify.” “I can’t afford physical therapy.””I went to interviews, but no one will hire me because I’m old/have a prison record/have visible tremors/am overqualified.”

I work as hard as I can. The clinicians I work with often double as social workers for these patients, helping them finding crisis housing when they lose their apartment, filling out paperwork for them to be brought to the doctor’s office when their clunker dies, finding vocational opportunities that allow them to find work, even if a few hours a week.

For this work that I do, the government pays me a salary that puts me squarely in the top 10 percentile of the income distribution. This salary is considerably lower than what other specialists make, and considerably lower than what I would make if I were in private practice, or employed by a for profit hospital or university. It is more than enough for what I consider a very comfortable life.

And I’m grateful for this. I’m grateful for the opportunity to remain in this diverse, open country, grateful for the opportunity to do what I do best, grateful that my 30-35% taxes pay for this health center, the roads, the traffic lights, the police, the EMS, urgent care centers, housing shelters, and yes, various forms of government assistance.

Because I come from a country where there is no government assistance. Every day, I’m aware of the fact that most of my patients, had they been in India, would either die, or resort to begging on the street in order to survive. This nation allows them not to do that. And for that, I’m grateful.

*Disclosure- I am neither a Democrat or a Republican. Being on a visa, I cannot vote. Like most Americans, I try to see beyond the smoke screens both parties put out. I don’t completely support either side, but have a clear bias towards one.

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The shocking facts about shock treatment.

Have you ever heard a medical war story?
I died on the table, and they brought me back twice. Broke two of my left ribs. The doc said it was a miracle.

You probably have. How about a psychiatric war story?
I was so depressed I wanted to kill myself; they gave me shock treatments and I got all better. Look at me now.

You probably haven’t. The reason is not that stories about ECT, electro-convulsive therapy, don’t exist*; it is because there is still a huge amount of stigma about mental illness in general and about ECT in particular. It is not something you talk about when you run into an old friend at the grocery store.

We’re all familiar with the horror stories, though, the images burned into our minds from years of TV and cinema. A feisty, likeable young man strapped down on the gurney, shocked with naked wires till his hair singes, turned into a zombie staring into space.  Our hearts turn with indignation. How dare they?

I ran into some of that recently, on Twitter. A simple comment about the effectiveness of ECT brought on the wrath of the antipsychiatry folks.

You’re mixing electricity with water!
Doctors just love to strap people down and shock them don’t they?
Have you had ECT yourself? You seem to have very strong feelings about it.

The wrath has persisted – even when I and two other psychiatrists clearly stated that yes, if severely depressed, we would choose ECT as a treatment for ourselves. It’s no surprise; there is little knowledge and plenty of misinformation about ECT amongst both patients and doctors.
Let’s talk about ECT, then.

What is ECT?
During ECT, a small electric current, smaller than a Taser or a cardiac defibrillator, is applied to the person’s temple to induce a generalized seizure, lasting 15-45 seconds.

How does it work?
*Edited. There is no definitive answer to exactly how ECT works, but there are several well documented changes in the brain. The small seizure releases several neuro-chemicals in the brain. It also modulates the activity of several brain centers, such as the frontal cortex, prefrontal cortex, and cingulate cortex.

What is it used for?
The main use of ECT is in people who are severely depressed, often with strong suicidal thoughts, psychosis, catatonia, or severe malnutrition due to refusal of food.

ECT is not a first line treatment. It is usually considered in patients who have failed multiple treatments with several different medications and psychotherapies.

Is it better than other therapies?
Meta-analyses (collecting and analyzing multiple studies done over years) show that ECT is more effective than any other treatment used for severe major depression**. Significant improvement occurs in 70 to 90 percent of patients who receive ECT, compared with approximately 30 percent for medication.

In 2011, the FDA conducted its own systematic review and meta-analyses** with the following findings:
- An analysis of 5 randomized trials estimated that improvement on the depression rating scale was about 7.1 points greater in patients who received ECT compared with sham ECT.
- A review of 3 randomized trials found that ECT was more effective than placebo.
- An analysis of 8 randomized trials estimated that improvement on the depression rating scale was about 5.0 points greater in patients who received ECT compared with antidepressant medication.

Is it painful?
No. ECT is performed under anesthesia. Along with anesthetic, a muscle relaxant is usually administered so that the body does not shake, unlike a regular generalized seizure. This prevents accidental injuries during the convulsion.

There are two movements commonly seen during ECT- the initial facial grimace, which happens because electrodes directly placed on the temples cause the facial muscles to contract- it is often scary to students watching the procedure, but the patient does not feel a thing.
Second, a blood pressure cuff is placed on one ankle to prevent the muscle relaxant from reaching one foot. This allows the doctors to observe the seizure in the toes of one foot, to corroborate with the EEG.

What EEG?
An EEG- brain wave monitoring – is done during ECT. This allows the doctors to ensure an adequate seizure time, 15-45 seconds. This also allows them to use medication to terminate the seizure if it goes on longer than intended. An EKG-cardiac monitoring- is also commonly done.

What are the side effects? Can it kill the patient?
The death rate of ECT is 2 to 4 deaths per 100,000 treatments, making it one of the safest procedures performed under anesthesia. Death is mostly related to heart-related side effects. All patients must undergo a medical evaluation for clearance prior to receiving ECT, and a cardiac consultation is indicated for those with heart problems. Other side effects include aspiration pneumonia, fractures, injuries to the tongue or teeth, headache, and nausea.

What about the brain damage?
ECT causes three types of brain side effects:
- Acute confusion- this is a result of the seizure and anesthesia. It resolves in half an hour.
- Anterograde amnesia- decreased ability to retain new information. This usually resolves in 1-2 weeks after treatment.
- Retrograde amnesia- forgetting recent memories, for events that occur during the course of ECT and a few weeks- months prior to that. The deficits are greatest for knowledge about public events, rather than personal information. Some of the lost memories may return, while others may not. In one systematic review, 30-55% of patients reported persistent memory loss.***

The typical ECT patient is severely depressed and accepts some degree of memory loss as a reasonable tradeoff for improvement in depression.

Can someone be given ECT against their will?
ECT should be done with informed consent- a discussion of risks and benefits with the patient. It often involves patients watching videos of the procedure to assuage their anxiety, and they are given plenty of time to ask questions and decide if they want to proceed with treatment. Under rare circumstances, if a patient is too sick to give an adequate informed consent, the doctor may petition the court for a treatment order. ****

The trope of a poor, mentally ill person being given ECT against their will is just that, a trope. The typical ECT patient today is relatively affluent and receives ECT in a private center. State hospitals rarely offer the treatment.

For further information, please visit:
The National Institute of Mental Health. http://www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulation-therapies.shtml
JAMA. http://jama.jamanetwork.com/article.aspx?articleid=193642
UpToDate basics. http://www.uptodate.com/contents/electroconvulsive-therapy-ect-the-basics?source=see_link
UpToDate beyond the basics. http://www.uptodate.com/contents/electroconvulsive-therapy-ect-beyond-the-basics?source=see_link

* Surgeon/writer Sherwin Nuland gave this wonderful TED talk about the history of ECT and his own experience as an ECT patient. Please watch this video for a patient perspective. http://www.youtube.com/watch?v=oEZrAGdZ1i8

** FDA Executive Summary: Prepared for the January 27-28, 2011 meeting of the Neurological Devices Panel. Meeting to Discuss the Classification of Electroconvulsive Therapy Devices (ECT). http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/NeurologicalDevicesPanel/UCM240933.pdf

**UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 2003; 361:799.

*** Rose D, Fleischmann P, Wykes T, et al. Patients’ perspectives on electroconvulsive therapy: systematic review. BMJ 2003; 326:1363.

****The only time I saw a court ordered ECT in 6 years of training was an elderly patient, depressed to the point of zero communication. He was completely immobile, could not eat, could not use the restroom. He stayed so still for such a long time that contractures developed in all 4 limbs. Since he could not communicate his wishes, the doctors petitioned the court. After 6 ECT treatments, he started communicating enough to be able to work with physical therapy, and eventually became mobile enough to walk short distances with a walker. I will never forget the first day he smiled at me.

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How it all went down. (V)

The 15 minute ride to  the community mental health center is over soon. It’s a beautiful building, nestled between well manicured lawns. The clinic where I work looks nothing like this. Still, it’s a community mental health center. This is where I have been working for the past 6 months- I know this population. It makes me feel confident.

We meet our team leader, go through a smaller orientation, and are asked to wait in what appears to be a group room. There is a smaller room off to one side with food and drinks, labeled For Candidates! I make myself my third cup of coffee of the day. We all gather around the table, making small talk. Someone leaves for a walk, someone else catches a nap. There is no cellphone reception. An hour passes by.

Our team leader is back. He leads us down the hallway to meet the examiners. I am introduced to my examiners, one a generic handsome doctor type and the other an older swarthy looking gentleman with an inverted U shaped mouth. I follow the examiners into a clinic room.

The patient is already seated as we walk in. I take my seat at the desk. The examiners sit to one side, poker faces on. My patient is a middle aged woman, pleasant and eager to cooperate. I launch into my standard introduction, amended to include a brief line about the examiners. While talking, I draw lines on the writing pad, dividing it neatly into 8 blocks. I have done this thousands of times. This is easy.

History of Present Illness.

Past Psychiatric History.

Medical History.

Substance Abuse.

Family History.

Social History.

Mental Status Exam.

Assessment and Plan.

I let her talk freely for the first five minutes, barely interrupting, scribbling notes in the columns where they fit, sifting words into data now since there will be no time later. Never actually looking at the paper. She has the rhythm of someone who’s been in the system for a while, and knows what to say. So far so good.

Next, I start probing, leading with open ended questions, then following with more concise ones. At some point, I make a comment, trying to clarify her thoughts during a period of sickness. She turns to the examiners and says words that are pure exam joy- “She’s Good!” The examiners don’t blink. We carry on.

One of the examiners calls out the five minute warning. My patient, bless her, has given me enough information to fill in all my little boxes. We do a quick mental status exam and I thank her for her time. She smiles, wishes me good luck, and leaves.

My examiners don’t give me the usual couple of minutes to gather my thoughts. Dr. Inverted U hangs back while Dr. Handsome starts questioning me. I answer the questions as I would while discussing a case with colleagues- my case summary, differential diagnosis, plan. As we dig deeper, I realize I don’t have enough information on her current family situation. The examiners know this- Dr. Handsome asks me to hazard a guess. I do- he maintains his poker face, while Dr. U nods in the background. For the rest of the Q&A, I make sure to look at Dr. U- he keeps nodding.

And just like that, it’s over. We spill out of our clinic rooms, visibly more relaxed, grinning, suddenly hungry as we walk back to the bus. It turns out that the examiners are taking the same bus back to the hotel as the examinees. This dissuades most people from exam talk, and we spend the rest of the ride swapping restaurant reviews.

Once back in the car, I text my friend. We meet soon after, going out for dinner, treating ourselves to ice cream. Talking about our cases. Both of us agree that we might pass, but the three week wait is going to be hard.

As it happens, the results comes out in less than two weeks. I pass. So do my friends, new and old. Now we can get back to the actual practice of medicine as opposed to the stylized performance of the Oral board exam.

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How it all went down. (IV)

Exam day.

I wake up before the alarm goes off. The exam is not until noon, and there is time to spare. I eat a leisurely waffles-and-yogurt breakfast in the hotel lobby, returning to my room only when it’s time to get ready. In a token gesture of rebellion, I’ve decided not to wear a full suit. Instead, I dress in black pants and a semi formal jacket. I check my ID, throw a granola bar and a water bottle in my bag and leave for the exam hotel.

The hotel lobby is full of examinees, reviewing notes, talking to each other, watching their watches. I notice a woman from the course- her mother is with her, handing out snacks, socks, papers. I get a coffee and call the husband for a last minute pep talk. Soon, it’s time to board the bus.

The bus is taking us to the local university medical center. The man next to me engages the bus driver in small talk- I am thankful for that. The bus driver points out local landmarks, including Warren Buffet’s high school. Soon they start talking about football and I drift off.

The exam center is in a modern looking medical building, all glass and curves. New-ish, bright artwork adorns the walls. We walk in, holding doors for each other, making small talk, laughing nervously. The first floor seems curiously empty. Then I remember- it’s Sunday.

Up on the second floor, our team leader greets us. I recognize her as the program director of a residency program where I was offered a position and had to decline. She seems to recognize me as well, but does not say anything, launching into a well rehearsed speech about the exam process. Since she is not one of the examiners, it does not really matter if she knows me. I try not to think about it too much. After she is done, we are led to a hallway where the examiners are waiting. Our names are called and we are introduced to our examiners. We shake hands and follow them to the exam rooms.

It’s on.

The vignettes are played much like musical chairs. All of us walk into our respective rooms. My first vignette is about a dementia/pseudodementia case. I give a happy inwards sigh- this is my subspecialty. The examiner lifts his eyebrows when I list rarely used dementia meds with their doses, titration schedules, current evidence- I risk a smile. He smiles back. The rest of it flies by.

Time to step out, switch doors, step into room 2. The second examiner is an older Indian/Pakistani psychiatrist. The vignette is about metabolic syndrome- the weight gain/hypertension/hypercholesterolemia/increased risk of diabetes that seem to come with a lot of antipsychotics. I feel comfortable with this, starting with how I would educate the patient, monitor weight, blood pressure, etc, refer to primary care, consider other, less risky medications. He presses me until I give him the word ‘psychoeducation’. Somehow, we end up talking about the few first generation antipsychotics that are weight neutral but rarely used. I’m hoping he gives me bonus points for knowing which ones are not available in the US anymore. Soon, time’s up.

My third vignette is trickier- a young woman with sudden onset anxiety symptoms, referred by her PCP. They clearly sound like anxiety due to a medical condition. I talk about hyperthyroidism, pheochromocytoma, even plunging into other endocrine tumors, a hazy territory for me. She keeps asking for more. I veer back to psychiatry, listing possible psychiatric disorders lower on my list. She keeps digging until we run out of time. What did I miss?

Out in the hallway, I try to focus on what the team leader said about using these minutes to ‘take a deep breath and just clear your mental screen, like an iPad’. Time for vignette 4.

This is a video vignette, a classic borderline patient admitted after an overdose. We discuss defense mechanisms. I refrain from saying the word ‘borderline’ with it’s negative connotations, and stick to describing the actual behaviors obvious from the video. My examiner seems satisfied, though she maintains a poker face.

Half time. We walk outside into the sunshine and take the bus to the local community mental health center for the live patient interview.

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How it all went down. (III)

Day 4 is my live patient interview. It’s the last interview of the course, and the room is packed with doctors. The patient has chronic schizophrenia- her face is flat and she says very little. I sink my heels in the carpet to make myself wait for her responses- they are there when I give her time. We manage to cover all the important topics- psychosis, suicide, homicide, medications, living situation. After the interview is over, my interviewer grills me. She is rude and impatient, asking multiple questions in one breath, not waiting for my responses. At one point, I answer a question with “a couple of times a month”. She fires back, “How much is a couple- 2, 3, 10?” I am confused. Once the mock interview is over, everyone applauds. She tells me I did great. I walk out, still confused and upset.

Out in the courtyard, my friends confirm my suspicions. “This is what she does with everyone. That’s why there was such a crowd- people have been coming to observe ‘the drillings’.” The military psychiatrist has teamed up with the Bangladeshi doc and is teaching him to organize his notes. I join in, sharing my templates, dos and don’ts. Later he takes us out to dinner to say thanks. We run into others, some of whom stop to shake my hand and tell me how well I did. I feel better. Over Chinese food, we talk about families. Pictures of spouses and children are shared, fortune cookies read. The course is over.

Day 5 is a free day for us. My friend schedules us a massage and we meet for brunch. Sitting there on the patio with our iced teas and salads, we can almost pretend this is a vacation. The spa bolsters that feeling. My masseuse is soft spoken and gentle. I close my eyes and ignore the life size Buddha statue in the corner- it embarrasses me to be naked before the Buddha. When she turns me over, I notice the bars on the ceiling. “What are those for?” “Those are for the Ashiatsu massage. I use them for support when I do the massage with my feet.” Falling into the massage haze, I wonder if I’d ever let anybody walk on my spine with their feet.

That evening, friends from residency start flying in. I meet one of them for Ethiopian food. She’s working in community psychiatry as well- we exchange war stories. The restaurant owner mothers over us and scolds us for not licking clean our humongous platters of food. Chastened, we get leftovers packed and vow to eat them for lunch the next day.

On day 6, we show up for registration and to receive our exam schedules. I will be one of the people taking the exam at two different locations. After the vignette exam at a local University medical center, I will take the shuttle to a community mental health center for the live patient interview. The speaker, head of the board, urges us repeatedly- “Do not miss the bus. Do not decide to drive yourself. Please, please, please, don’t decide to put your photo ID in a new and special place.” All my friends have their exams at a single location. I try not to feel bummed. Instead, a friend and I go out for coffee and I get a new battery for my rarely used watch. I will need it for the exam- they gave us timers at the course, but beeping time keeping devices are not allowed at the exam.

That evening, four of us from the residency program meet up for an outdoor Italian dinner. We discuss jobs, goats, and fathers. Thunder strikes as soon as we put down our forks. The tea light draped tree under which we are sitting trembles. Fat drops of water hit the table. Determined to have our just desserts, we run to the ice cream shop, taking shelter under awnings when we can. The shop is crowded even in the rain, with the line snaking double upon itself. We end up leaving without ice cream. I drop my friends at their hotel and drive back very carefully. Tomorrow is exam day.

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